Cecal intubation rates in different eras of endoscopic technological development

Introduction

Colonoscopy plays a critical role in colorectal cancer (CRC) screening and has been widely regarded as the gold standard. Cecal intubation rate (CIR) is one of the well-defined quality indicators used to assess colonoscopy.

Aim

To assess the impact of new technologies on the quality of colonoscopy by assessing completion rates.

Material and methods

This was a dual-center study at the 2^nd Department of Surgery at Jagiellonian University Medical College and at the Specialist Center “Medicina” in Krakow, Poland. The CIR and cecal intubation time (CIT) in three different eras of technological advancement were determined. The study enrolled 27 463 patients who underwent colonoscopy as part of a national CRC screening program. The patients were divided into three groups: group I – 3408 patients examined between 2000 and 2003 (optical endoscopes); group II – 10 405 patients examined between 2004 and 2008 (standard electronic endoscopes); and group III – 13 650 patients examined between 2009 and 2014 (modern endoscopes).

Results

There were statistically significant differences in the CIR between successive eras. The CIR in group I (2000–2003) was 69.75%, in group II (2004–2008) was 92.32%, and in group III (2009–2014) was 95.17%. The mean CIT was significantly reduced in group III.

Conclusions

Our study shows that the technological innovation of novel endoscopy devices has a great influence on the effectiveness of the CRC screening program. The new era of endoscopic technological development has the potential to reduce examination-related patient discomfort, obviate the need for sedation and increase diagnostic yields.

Validity of the diagnosis of appendicitis in the Danish National Patient Register

Aims: Appendicitis is a common disease. The nationwide Danish National Patient Register provides an important data source for epidemiological research. Data used in register-based epidemiological research needs to be validated. We aimed to validate the diagnosis of appendicitis in the Danish National Patient Register. Methods: From 1997 to 2015 nationwide data from the Danish National Patient Register, the Danish Pathology Register, and the Danish Civil Registration System were used to validate the diagnosis of appendicitis or the combination of the diagnosis for appendicitis and surgical removal of the appendix in the Danish National Patient Register. Sensitivity, specificity, and positive and negative predictive values were calculated using pathology reports as golden standard. Results: Diagnosis of appendicitis in the Danish National Patient Register had a sensitivity, specificity, positive predictive value, and negative predictive value of 0.928 (95% confidence interval (CI): 0.927; 0.930), 0.995 (95% CI: 0.995; 0.995), 0.769 (95% CI: 0.767; 0.771), and 0.999 (95% CI: 0.999; 0.999). A diagnosis of appendicitis and a procedure code for surgical removal of the appendix had a sensitivity, specificity, positive predictive value, and negative predictive value of 0.886 (95% CI: 0.885; 0.888), 0.998 (95% CI: 0.998; 0.998), 0.895 (95% CI: 0.894; 0.897), and 0.998 (95% CI: 0.998; 0.998). Conclusions: The diagnosis of appendicitis alone or in combination with the registered surgical removal of the appendix in the Danish National Patient Register showed acceptable validity. Whether to use the diagnosis for appendicitis only or in combination with procedure codes for the removal of the appendix depends on whether high sensitivity or high positive predictive values are warranted.

Data Improvement Through Simplification: Implications for Low-Resource Settings

BACKGROUND

The focus of many data collection efforts centers on creation of more granular data. The assumption is that more complex data are better able to predict outcomes. We hypothesized that data are often needlessly complex. We sought to demonstrate this concept by examination of the American Society of Anesthesiologists (ASA) scoring system.

METHODS

First, we created every possible consecutive two, three and four category combinations of the current five category ASA score. This resulted in 14 combinations of simplified ASA. We compared the predictive ability of these simplified scores for postoperative outcomes for 2.3 million patients in the NSQIP database. Individual model performance was assessed by comparing receiver operator characteristic (ROC) curves for each model with the standard ASA.

RESULTS

Two of our 4-category models and one of our 3-category models had ability to predict all outcomes equivalent to standard ASA. These results held for all outcomes and on all subgroups tested. The performance of the three best performing simplified ASA scores were also equivalent to the standard ASA score in the univariate analysis and when included in a multivariate model.

CONCLUSIONS

It is assumed that the most granular data and use of the largest number of variables for risk-adjusted predictions will increase accuracy. This complexity is often at the expense of utility. Using the single best predictor in surgical outcomes research, we have shown this is not the case. In this example, we demonstrate that one can simplify ASA into a 3-category variable without losing any ability to predict outcomes.

2017 WSES guidelines for the management of iatrogenic colonoscopy perforation

Iatrogenic colonoscopy perforation (ICP) is a severe complication that can occur during both diagnostic and therapeutic procedures. Although 45-60% of ICPs are diagnosed by the endoscopist while performing the colonoscopy, many ICPs are not immediately recognized but are instead suspected on the basis of clinical signs and symptoms that occur after the endoscopic procedure. There are three main therapeutic options for ICPs: endoscopic repair, conservative therapy, and surgery. The therapeutic approach must vary based on the setting of the diagnosis (intra- or post-colonoscopy), the type of ICP, the characteristics and general status of the patient, the operator's level of experience, and surgical device availability. Although ICPs have been the focus of numerous publications, no guidelines have been created to standardize the management of ICPs. The aim of this article is to present the World Society of Emergency Surgery (WSES) guidelines for the management of ICP, which are intended to be used as a tool to promote global standards of care in case of ICP. These guidelines are not meant to substitute providers' clinical judgment for individual patients, and they may need to be modified based on the medical team's level of experience and the availability of local resources.

Serum cytokines in early prediction of anastomotic leakage following low anterior resection

Introduction

Anastomotic leakage continues to be one of the most serious complications following low anterior resections. Early diagnosis of a leak is difficult but critical to minimize morbidity and mortality.

Aim

To evaluate changes in serum concentrations of 27 different cytokines following low anterior resection, with the goal of finding new, early biomarkers of anastomotic leak.

Material and methods

This is a prospective observational study that includes 32 patients undergoing elective low anterior resection for rectal cancer. Blood samples were collected preoperatively and on postoperative day 3.

Results

Five patients developed anastomotic leak (15%). On postoperative day 3, high-sensitivity C-reactive protein (hs-CRP), interleukin (IL)-6, and regulated on activation, normal T cell expressed and secreted (RANTES) were significantly higher in patients with anastomotic leak, while IL-9 and fibroblast growth factor (FGF) 2 were significantly lower. Analysis of relative changes in the concentration of cytokines from preoperative to postoperative day 3 revealed a significant increase of IL-6 and granulocyte-colony stimulating factor (G-CSF) in patients with an anastomotic leak. Upon receiver operating curve (ROC) analysis, the performance of hs-CRP was found to be excellent (AUC = 0.99), and performance of ΔIL-6, IL-6, RANTES, and FGF2 was good (AUC: 0.81–0.87). Patients who developed an anastomotic leak preoperatively had significantly lower levels of macrophage inflammatory protein-1 α (MIP-1α), monocyte chemotactic protein-1 (MCP-1), IL-8, FGF2, and G-CSF.

Conclusions

The single most accurate serum biomarker of anastomotic leakage continues to be hs-CRP. However, when analyzing relative changes of cytokine levels, ΔIL-6 appears to be a better leak predictor than CRP.

Predictors of morbidity and mortality post emergency abdominal surgery: A national study

BACKGROUND/AIM

Emergency surgeries have increased in Saudi Arabia. This study examines these surgeries and associated complications.

PATIENTS AND METHODS

This was a prospective multicenter cohort study of patients undergoing emergency intraperitoneal surgery from the eight health sectors of Saudi Arabia. Patients' data were collected over 14 days.

RESULTS

In total, 283 patients were included (163 men [54.06%]). The majority of cases were open surgery (204 vs. 79). The 24 h and 30-day mortality rates for the cohort were 0.7 and 2.47%, respectively. Twenty-nine patients (10.24%) required re-intervention, while 19 (8.12%) needed critical care admission. The median length of hospital stay was 3 days. Multivariate analysis showed American Society of Anesthesiologist (ASA) classification score (P = 0.0003), diagnosis (P < 0.0001), stoma formation (P = 0.0123), and anastomotic leak (P = 0.0015) to correlate significantly with 30-day mortality.

CONCLUSION

American Society of Anesthesiologist score, diagnosis, stoma formation and anastomotic leak are associated with 30-day mortality after emergency surgery in Saudi Arabia.

Intraoperative use of ICG fluorescence imaging to reduce the risk of anastomotic leakage in colorectal surgery: a systematic review and meta-analysis

BACKGROUND

Indocyanine green (ICG) fluorescence imaging has been proven to be an effective tool to assess anastomotic perfusion. The aim of this systematic review and meta-analysis was to evaluate its efficacy in reducing the anastomotic leakage (AL) rate after colorectal surgery.

METHODS

PubMed, Scopus, WOS, Google Scholar and Cochrane Library were searched up to January 2017 for studies comparing fluorescence imaging with standard care. ClinicalTrials.gov register was searched for ongoing trials. The primary outcome measure was AL rate with at least 1 month of follow-up. ROBINS-I tool was used for quality assessment. A meta-analysis with random-effects model was performed to calculate odds ratios (ORs) from the original data.

RESULTS

One thousand three hundred and two patients from 5 non-randomized studies were included. Fluorescence imaging significantly reduced the AL rate in patients undergoing surgery for colorectal cancer (OR 0.34; CI 0.16-0.74; p = 0.006). Low AL rates were shown in rectal cancer surgery (ICG 1.1% vs non-ICG 6.1%; p = 0.02). There was no significant decrease in the AL rate when colorectal procedures for benign and malignant disease were combined. To date, there are no published randomized control trials (RCTs) on this subject, though 3 ongoing RCTs were identified.

CONCLUSIONS

ICG fluorescence imaging seems to reduce AL rates following colorectal surgery for cancer. However, the inherent bias of the non-randomized studies included, and their differences in AL definition and diagnosis could have influenced results. Large well-designed RCTs are needed to provide evidence for its routine use in colorectal surgery.

Guide to research in academic global surgery: A statement of the Society of University Surgeons Global Academic Surgery Committee

Global surgery is an emerging academic discipline that is developing in tandem with numerous policy and advocacy initiatives. In this regard, academic global surgery will be crucial for measuring the progress toward improving surgical care worldwide. However, as a nascent academic discipline, there must be rigorous standards for the quality of work that emerges from this field. In this white paper, which reflects the opinion of the Global Academic Surgery Committee of the Society for University Surgeons, we discuss the importance of research in global surgery, the methodologies that can be used in such research, and the challenges and benefits associated with carrying out this research. In each of these topics, we draw on existing examples from the literature to demonstrate our points. We conclude with a call for continued, high-quality research that will strengthen the discipline's academic standing and help us move toward improved access to and quality of surgical care worldwide.

Recommendations for Randomised Trials in Surgical Oncology

Trials of surgical procedures in the treatment of malignant disease face a unique set of challenges. This review aimed to describe recommendations for the design, delivery and reporting of randomised trials in surgical oncology. A literature search was carried out without date limits to identify articles related to trial methodology research in surgery and surgical oncology. A narrative review was framed around two open National Institute of Health Research portfolio trials in colon and rectal cancer: the STAR-TREC trial (ISRCTN14240288) and the ROCCS trial (ISRCTN46330337). Twelve specific challenges were highlighted: standardisation of technique; pilot and feasibility studies; balancing treatments; the recruitment pathway; outcome measures; patient and public representation; trainee-led networks; randomisation; novel techniques and training; learning curves; blinding; follow-up. Evidence-based recommendations were made for the future design and conduct of surgical oncology trials. Better understanding of the challenges facing trials in the surgical treatment of cancer will accelerate high-quality evaluation and rapid adoption of innovation for the benefit of patient care.

Value of social media in advancing surgical research

Spreading the word

Surgical safety checklist training: a national study of undergraduate medical and nursing student teaching, understanding and influencing factors

INTRODUCTION

Use of the WHO surgical safety checklist is consistently recognised to reduce harm caused by human error during the perioperative period. Inconsistent engagement is considered to contribute to persistence of surgical Never Events in the National Health Service. Most medical and nursing graduates will join teams responsible for the perioperative care of patients, therefore appropriate undergraduate surgical safety training is needed.

AIMS

To investigate UK medical and nursing undergraduate experience of the surgical safety checklist training.

METHODS

An eight-item electronic questionnaire was distributed electronically to 32 medical schools and 72 nursing schools. Analysis was conducted for the two cohorts, and responses from final year students were included.

RESULTS

87/224 (38.8%) of medical students received teaching on the surgical safety checklist, compared with 380/711 (52.0%) of nursing students. 172/224 (76.8%) of medical students and 489/711 (66.9%) of nursing students understood its purpose and 8/224 (3.6%) medical students and 54/711 (7.4%) nursing students reported never being included in the Time Out. After adjusting for confounding factors, provision of formal teaching in checklist use increased understanding significantly (OR 50.39 (14.07 to 325.79, P<0.001)), as did routine student involvement in time outs (OR 5.72 (2.36 to 14.58, P<0.001)).

DISCUSSION

Knowledge of perioperative patient safety systems and the ability to participate in safety protocols are important skills that should be formally taught at the undergraduate level. Results of this study show that UK undergraduate surgical safety checklist training does not meet the minimum standards set by the WHO.

CT guided appendicectomy incision: A prospective case series

OBJECTIVE

Several radiological studies have suggested that the base of the Appendix often does not correspond with Mc Burney's point. The aim of our study is to assess the value of using CT localization of the appendicocaecal junction to guide placement of the appendicectomy incision.

DESIGN & METHOD

32 consecutive patients, booked for open appendicectomy were prospectively included in this study. Coronal and axial CT scans with IV contrast were studied to assess site of the appendicocaecal junction. This information was used to guide placement of the incision.

RESULTS

28 out of 32 patients studied, the appendicocaecal junctions were accurately identified. It was noted that the final incision sites were cephalad to Mc Burney's point in 8, at the point in 3 and caudal in 17. In 1 patient, it was necessary to extend the incision medially by 2cm to retrieve the distal Appendix which had been detached through the site of rupture.

CONCLUSION

Mc Burney's point often does not correspond to the base of the appendix. We propose that using CT imaging to guide the appendicectomy incision is safe, facilitates locating the Appendix at surgery, minimizes incision size and decreases the need to extend it.

Laparoscopic pyloroplasty for perforated peptic ulcer

Peptic ulcer is a common disease affecting millions of people every year. Despite improved understanding and treatment of the disease, the number of patients admitted with duodenal peptic ulcer perforation has not decreased. Deaths from peptic ulcer disease overcome other common emergency situations. Laparoscopic repair of the perforated peptic ulcer (PPU) is the gold standard approach for simple perforation. However, in patients with large perforated chronic ulcers laparotomy with pyloroplasty is the standard treatment. It is generally accepted to perform open surgery in PPU emergencies because of the greater knowledge and experience gathered over the past decades and less potential harm for the patient or surgical complications. We present a case of successful laparoscopic pyloroplasty of a perforated duodenal ulcer with stenosis.

#colorectalsurgery

BACKGROUND

The use of social media platforms among healthcare professionals is increasing. A Twitter social media campaign promoting the hashtag #colorectalsurgery was launched with the aim of providing a specialty-specific forum to collate discussions and science relevant to an engaged, global community of coloproctologists. This article reviews initial experiences of the early adoption, engagement and utilization of this pilot initiative.

METHODS

The hashtag #colorectalsurgery was promoted via the online microblogging service Twitter across a 180-day interval. Data on all tweets containing the #colorectalsurgery hashtag were analysed using online analytical tools. Data included total number of tweets, number of views, and user engagement since registration and launch of the campaign. Content of tweet and user demographic analysis was undertaken.

RESULTS

The number of tweets using #colorectalsurgery grew rapidly following the launch on 24 April 2016; #colorectalsurgery was used in 15 708 tweets, which resulted in 65 398 696 impressions and involved 1863 individual Twitter accounts. Increased volumes of #colorectalsurgery tweets were noted in association with the timing of three major international colorectal surgical conferences, and geographical trends were noted. Some 88·4 per cent of all posts were by male users. The top 25 users by volume of #colorectalsurgery tweets had considerable influence and posted 8023 tweets (51·1 per cent).

CONCLUSION

Online global communities formed via healthcare-related hashtags, such as #colorectalsurgery, unify social media posts, scientists, surgeons and authors who have an interest in coloproctology. Furthermore, they facilitate greater connectivity among geographically separate users.

The Bigger Picture: Picking the Right Soap Box-Is it Possible to Connect with Different Audience Targets (Practitioners and Patients) from the Same Platform?

The use of Internet and social media has skyrocketed in the past decade. It did not take long until physicians realized that they could use social media as a tool for communication with patients and colleagues. Since then use of social media has exploded and the information that has become available for physicians and their patients is remarkable. In addition, because of the immediacy of the platform, messages that are incorrect or not desired can be rapidly promoted, whether deliberately or accidentally. To obtain the best use of social media, the right platform should be chosen, and this varies depending on the group one is trying to reach, and the message or visibility desired. In this article, we review the variety of options available to users.

The effect of systematic factors on the outcome of trauma laparotomy at a major trauma centre in South Africa

Introduction The aim of this study was to examine and interrogate outcomes in trauma laparotomy in a South African trauma centre to determine whether systematic factors were associated with any discrepancies in outcome. Methods This was a retrospective review of a prospectively entered trauma registry undertaken at the Pietermaritzburg Metropolitan Trauma Service, Pietermaritzburg, South Africa. The service has developed a hybrid electronic medical record system (HEMR) where clinical data were captured in real time, which were incorporated this into a database. Results During the period from December 2012 to July 2016, 562 patients underwent emergency laparotomy for trauma and the time and date of surgery was recorded in the HEMR. The mean age of all patients was 29.5 years. There were 256 operations during the weekend or over a public holiday, with a mortality of 8% (n = 21) compared with 306 during the week (mortality of 10%, n = 31). This difference was not statistically significant (P = 0.237). A total of 327 operations were performed at night (18:00 - 08:00) and 235 operations were performed during the day (08:00-18:00 Hours). This was a significant difference in mortality (10% (33) vs 7 % (16), P=0.013) These differences persisted if weekends and public holidays were separated out from normal working days. A total of 188 operations were performed on a week night, with a mortality of 11% (n = 20) and 121 operations were performed during a week day, with a mortality of 8% (n = 10). There were 139 operations on a weekend or public holiday night, with a mortality of 9% (n = 13). A total of 114 operations were performed on a weekend or public holiday day with a mortality of 7% (n = 8). A total of 208 procedures were performed with an consultant present. Of these, 32 patients (15%) died. A total of 368 procedures were performed without a consultant present and 8 (2%) died. Conclusions This study demonstrated a discrepancy in outcome for trauma laparotomy, depending on whether the operation was performed at night or during the day. The reasons for this are unclear, although the lack of consultant presence at night in comparison to during the day appears to be implicated.

Determining the worldwide epidemiology of surgical site infections after gastrointestinal resection surgery: protocol for a multicentre, international, prospective cohort study (GlobalSurg 2)

INTRODUCTION

Surgical site infection (SSI) is the most common complication following major gastrointestinal surgery, affecting between 25% and 40% of patients. The rate of SSI doubles from low-income to high-income settings, persisting after risk adjustment. The relative impact of antibiotic-resistant organisms and the effectiveness of antibiotic prophylaxis globally are unknown. This study aims to determine SSI rates following gastrointestinal surgery across worldwide hospital settings.

METHODS AND ANALYSIS

This multicentre, international, prospective cohort study will be undertaken by any hospital providing emergency or elective gastroenterological surgical services. Centres will collect observational data on consecutive patients undergoing emergency or elective gastrointestinal resection, cholecystectomy or appendicectomy during a 6-month period. The primary outcome is the incidence of SSI with secondary outcomes describing the organisms causing SSIs, including their antibiotic susceptibility, and the microbiological tests used to identify them.

ETHICS AND DISSEMINATION

This project will not affect clinical practice and has been classified as clinical audit following research ethics review. The protocol will be disseminated through the international GlobalSurg network.

TRIAL REGISTRATION NUMBER

NCT02662231.

Emergency appendicectomy in Australia: findings from a multicentre, prospective study

BACKGROUND

Emergency appendicectomy is the most common emergency surgical procedure performed in Australia. Despite this frequency, there is a relative paucity of contemporary, broad-based, local data that examine how emergency appendicectomies are currently performed and what are the outcomes from these operations.

METHODS

A multicentre, prospective, observational study was performed. Patients were recruited by local investigators for a period of 2 months with 30-day follow-up. Patients were eligible for study inclusion if they underwent an emergency appendicectomy for suspected acute appendicitis. The primary outcome of the study was the negative appendicectomy rate (NAR), with secondary outcomes including 30-day complication rates, method of operation and conversion rates.

RESULTS

A total of 1189 patients were recruited across 27 centres. The NAR across all centres was 19.0%. 98.2% of appendicectomies were performed with a laparoscopic-first approach. The rate of conversion from laparoscopy to open operation was 2.4%. 9.4% of patients were recorded as having one or more of the following complications: readmission (6.6%), surgical site infection (1.9%), intra-abdominal abscess (2.7%) or further intervention (1.5%). Patients who had an open operation had higher rates of readmission and surgical site infection.

CONCLUSION

The NAR found in this study is within the traditional measures of acceptance; however, this rate is high when measured against modern international benchmarks.

Results of the FIT-based National Colorectal Cancer Screening Program in Slovenia

BACKGROUND

Colorectal cancer (CRC) is one of the most common malignancies in the western world.

OBJECTIVE

We aimed to assess the first round of fecal immunochemical test (FIT)-based National CRC screening program (NCSP).

METHODS

In the NCSP conducted in Slovenia, a FIT and colonoscopy for those tested positive was used. The NCSP central unit sent 536,709 invitations to Slovenian residents age 50 to 69 years old between 2009 and 2011. The adherence rate was 56.9% (303,343 participants). FIT was positive in 6.2% (15,310) of the participants (men, 7.8%; women, 5.0%; P<0.01). A total of 13,919 unsedated colonoscopies were performed with the cecal intubation rate of 97.8%.

RESULTS

The overall adenoma detection rate was 51.3% [95% confidence interval (CI), 50.5%-52.1%] of which 61.0% (95% CI, 59.9%-62.1%) was in men, and 39.1% (95% CI, 37.8%-40.3%) in women (P<0.01). The mean number of adenoma per positive colonoscopy was 1.94 (95% CI, 1.90-1.97). Adenoma, advanced adenoma, or cancer were found in 7732 (55.5%) colonoscopies. A total of 862 (6.2%) CRC cases were found. Only 161 (18.7%) carcinomas were situated in the right colon. A total of 597 (70.2%) patients with cancer were in the early clinical stages (N, negative; 194 22.8%) of all cancers were cured with only endoscopic resection.

CONCLUSIONS

In the NCSP, CRC was found in 6.2% of those participants attending colonoscopy, with 81.3% of carcinomas found in the left colon. A localized clinical stage was found in 70.2% participants. In 22.8% of CRC patients, cancer was cured with endoscopic resection only.

Interval follow up of a 4-day pilot program to implement the WHO surgical safety checklist at a Congolese hospital

Background

The World Health Organisation Surgical Safety Checklist (SSC) improves surgical outcomes and the research question is no longer ‘does the SSC work?’ but, ‘how to make the SSC work?’ Evidence for implementation strategies in low-income countries is sparse and existing strategies are heavily based on long-term external support. Short but effective implementation programs are required if widespread scale up is to be achieved. We designed and delivered a four-day pilot SSC training course at a single hospital centre in the Republic of Congo, and evaluated the implementation after one year. We hypothesised that participants would still be using the checklist over 50% of the time.

Method

We taught the four-day SSC training course at Dolisie hospital in February 2014, and undertook a mixed methods impact evaluation based on the Kirkpatrick model in May 2015. SSC implementation was evaluated using self-reported questionnaire with a 3 point Likert scale to assess six key process measures. Learning, behaviour, organisational change and facilitators and inhibitors to change were evaluated with questionnaires, interviews and focus group discussion.

Results

Seventeen individuals participated in the training and seven (40%) were available for impact evaluation at 15 months. No participant had used the SSC prior to training. Over half the participants were following the six processes measures always or most of the time: confirmation of patient identity and the surgical procedure (57%), assessment of difficult intubation risk (72%), assessment of the risk of major blood loss (86%), antibiotic prophylaxis given before skin incision (86%), use of a pulse oximeter (86%), and counting sponges and instruments (71%). All participants reported positive improvements in teamwork, organisation and safe anesthesia. Most participants reported they worked in helpful, supportive and respectful atmosphere; and could speak up if they saw something that might harm a patient. However, less than half felt able to challenge those in authority.

Conclusion

Our study demonstrates that a 4-day pilot course for SSC implementation resulted in over 50% of participants using the SSC at 15 months, positive changes in learning, behaviour and organisational change, but less impact on hierarchical culture. The next step is to test our novel implementation strategy in a larger hospital setting.

An Evaluation of Preparedness, Delivery and Impact of Surgical and Anesthesia Care in Madagascar: A Framework for a National Surgical Plan

BACKGROUND

The Lancet Commission on Global Surgery (LCoGS) described the lack of access to safe, affordable, timely surgical, and anesthesia care. It proposed a series of 6 indicators to measure surgery, accompanied by time-bound targets and a template for national surgical planning. To date, no sub-Saharan African country has completed and published a nationwide evaluation of its surgical system within this framework.

METHOD

Mercy Ships, in partnership with Harvard Medical School and the Madagascar Ministry of Health, collected data on the 6 indicators from 22 referral hospitals in 16 out of 22 regions of Madagascar. Data collection was by semi-structured interviews with ministerial, medical, laboratory, pharmacy, and administrative representatives in each region. Microsimulation modeling was used to calculate values for financial indicators.

RESULTS

In Madagascar, 29% of the population can access a surgical facility within 2 h. Surgical workforce density is 0.78 providers per 100,000 and annual surgical volume is 135-191 procedures per 100,000 with a perioperative mortality rate of 2.5-3.3%. Patients requiring surgery have a 77.4-86.3 and 78.8-95.1% risk of incurring impoverishing and catastrophic expenditure, respectively. Of the six LCoGS indicator targets, Madagascar meets one, the reporting of perioperative mortality rate.

CONCLUSION

Compared to the LCoGS targets, Madagascar has deficits in surgical access, workforce, volume, and the ability to offer financial risk protection to surgical patients. Its perioperative mortality rate, however, appears better than in comparable countries. The government is committed to improvement, and key stakeholder meetings to create a national surgical plan have begun.

Setting the research and implementation agenda for equitable access to surgical care in South Africa

South Africa is an upper-middle-income country with widespread social and geographical inequality of surgical provision. The National Forum on Surgery and Anaesthesia in South Africa brought together various stakeholders, including government, societies, academic clinicians and the biomedical industry, to define the core strategy for a national surgical plan. During the forum, presentations and breakaway workshops explored and reported the challenges and opportunities these stakeholders may have in sustaining and improving surgical provision in South Africa. We present the recommendations of these reports with a literature review and other recent reports from organisations involved in healthcare systems in South Africa. We acknowledge the importance of access to safe and affordable surgery for all as a core component of healthcare provision for South Africa. The proposed core strategies for a South African National Surgical Plan to achieve these goals are the following. First, research will focus on high-quality interdisciplinary collaborative research and audit, which addresses the Global Surgery indices, adopts internationally consistent data points and focuses particularly on maternal mortality and the 'Bellwether procedures'. Second, workforce and training must be tailored to the country's specific surgical needs, based on a primary healthcare and district hospital model, which is supported by government and academic organisations. Third, the surgical infrastructure and service delivery needs to be strengthened by the district hospital. Finally, strong leadership with appropriate financial support by healthcare managers who partner with clinicians both locally and nationally is needed to achieve these objectives.

Colorectal cancer population screening programs worldwide in 2016: An update

Colorectal cancer (CRC) is the third most commonly diagnosed cancer in the world. The incidence and mortality show wide geographical variations. Screening is recommended to reduce both incidence and mortality. However, there are significant differences among studies in implementation strategies and detection. This review aimed to present the results and strategies of different screening programs worldwide. We reviewed the literature on national and international screening programs published in PubMed, on web pages, and in clinical guidelines. CRC Screening programs are currently underway in most European countries, Canada, specific regions in North and South America, Asia, and Oceania. The most extensive screening strategies were based on fecal occult blood testing, and more recently, the fecal immunochemical test (FIT). Participation in screening has varied greatly among different programs. The Netherlands showed the highest participation rate (68.2%) and some areas of Canada showed the lowest (16%). Participation rates were highest among women and in programs that used the FIT test. Men exhibited the greatest number of positive results. The FIT test has been the most widely used screening program worldwide. The advent of this test has increased participation rates and the detection of positive results.

Safety, productivity and predicted contribution of a surgical task-sharing programme in Sierra Leone

Background

Surgical task‐sharing may be central to expanding the provision of surgical care in low‐resource settings. The aims of this paper were to describe the set‐up of a new surgical task‐sharing training programme for associate clinicians and junior doctors in Sierra Leone, assess its productivity and safety, and estimate its future role in contributing to surgical volume.

Methods

This prospective observational study from a consortium of 16 hospitals evaluated crude in‐hospital mortality over 5 years and productivity of operations performed during and after completion of a 3‐year surgical training programme.

Results

Some 48 trainees and nine graduated surgical assistant community health officers (SACHOs) participated in 27 216 supervised operations between January 2011 and July 2016. During training, trainees attended a median of 822 operations. SACHOs performed a median of 173 operations annually. Caesarean section, hernia repair and laparotomy were the most common procedures during and after training. Crude in‐hospital mortality rates after caesarean sections and laparotomies were 0·7 per cent (13 of 1915) and 4·3 per cent (7 of 164) respectively for operations performed by trainees, and 0·4 per cent (5 of 1169) and 8·0 per cent (11 of 137) for those carried out by SACHOs. Adjusted for patient sex, surgical procedure, urgency and hospital, mortality was lower for operations performed by trainees (OR 0·47, 95 per cent c.i. 0·32 to 0·71; P < 0·001) and SACHOs (OR 0·16, 0·07 to 0·41; P < 0·001) compared with those conducted by trainers and supervisors.

Conclusion

SACHOs rapidly and safely achieved substantial increases in surgical volume in Sierra Leone.

Benchmark analysis

Sex disparities among persons receiving operative care during armed conflicts

BACKGROUND

Armed conflict increasingly involves civilian populations, and health care needs may be immense. We hypothesized that sex disparities may exist among persons receiving operative care in conflict zones and sought to describe predictors of disparity.

METHODS

We performed a retrospective analysis of operative interventions performed between 2008 and 2014 at Médecins Sans Frontières Operation Center Brussels conflict projects. A Médecins Sans Frontières Operation Center Brussels conflict project was defined as a program established in response to human conflict, war, or social unrest. Intervention- and country-level variables were evaluated. For multivariate analysis, multilevel mixed-effects logistic regression was used with random-effect modeling to account for clustering and population differences in conflict zones.

RESULTS

Between 2008 and 2014, 49,715 interventions were performed in conflict zones by Médecins Sans Frontières Operation Center Brussels. Median patient age was 24 years (range: 1-105 years), and 34,436 (69%) were men. Patient-level variables associated with decreased interventions on women included: American Society of Anesthesiologists score (P = .003), degree of urgency (P = .02), mechanism (P < .0001), and a country's predominant religion (P = .006). Men were 1.7 times more likely to have an operative intervention in a predominantly Muslim country (P = .006).

CONCLUSION

Conflict is an unfortunate consequence of humanity in a world with limited resources. For most operative interventions performed in conflict zones, men were more commonly represented. Predominant religion was the greatest predictor of increased disparity between sexes, irrespective of the number of patients presenting as a result of traumatic injury. It is critical to understand what factors may underlie this disparity to ensure equitable and appropriate care for all patients in an already tragic situation.

Enhancing quality of medical care in low income and middle income countries through simulation-based initiatives: recommendations of the Simnovate Global Health Domain Group

Background

Quality of medical care in low income and middle income countries (LMICs) is variable, resulting in significant medical errors and adverse patient outcomes. Integration of simulation-based training and assessment may be considered to enhance quality of patient care in LMICs. The aim of this study was to consider the role of simulation in LMICs, to directly impact health professions education, measurement and assessment.

Methods

The Simnovate Global Health Domain Group undertook three teleconferences and a direct face-to-face meeting. A scoping review of published studies using simulation in LMICs was performed and, in addition, a detailed survey was sent to the World Directory of Medical Schools and selected known simulation centres in LMICs.

Results

Studies in LMICs employed low-tech manikins, standardised patients and procedural simulation methods. Low-technology manikins were the majority simulation method used in medical education (42%), and focused on knowledge and skills outcomes. Compared to HICs, the majority of studies evaluated baseline adherence to guidelines rather than focusing on improving medical knowledge through educational intervention. There were 46 respondents from the survey, representing 21 countries and 28 simulation centres. Within the 28 simulation centres, teachers and trainees were from across all healthcare professions.

Discussion

Broad use of simulation is low in LMICs, and the full potential of simulation-based interventions for improved quality of care has yet to be realised. The use of simulation in LMICs could be a potentially untapped area that, if increased and/or improved, could positively impact patient safety and the quality of care.

Youth innovation showcase: achieving high-impact success with novel technologies

Universities provide a dynamic environment that enables innovation in healthcare. Challenges to the delivery of healthcare are best overcome by fostering relationships that lead to solutions developed by young innovators. The Youth Innovation Showcase highlights the creative solutions of 5 young entrepreneurs as part of the Simnovate International Summit. Challenges in the process of innovation, finding balance as a young innovator, government support for student entrepreneurs, innovation and global health and how to adapt to the process of innovation are all topics covered in this summary.

Surgical volume and postoperative mortality rate at a referral hospital in Western Uganda: Measuring the Lancet Commission on Global Surgery indicators in low-resource settings

BACKGROUND

The Lancet Commission on Global Surgery recommends that every country report its surgical volume and postoperative mortality rate. Little is known, however, about the numbers of operations performed and the associated postoperative mortality rate in low-income countries or how to best collect these data.

METHODS

For one month, every patient who underwent an operation at a referral hospital in western Uganda was observed. These patients and their outcomes were followed until discharge. Prospective data were compared with data obtained from logbooks and patient charts to determine the validity of using retrospective methods for collecting these metrics.

RESULTS

Surgical volume at this regional hospital in Uganda is 8,515 operations/y, compared to 4,000 operations/y reported in the only other published data. The postoperative mortality rate at this hospital is 2.4%, similar to other hospitals in low-income countries. Finding patient files in the medical records department was time consuming and yielded only 62% of the files. Furthermore, a comparison of missing versus found charts revealed that the missing charts were significantly different from the found charts. Logbooks, on the other hand, captured 99% of the operations and 94% of the deaths.

CONCLUSION

Our results describe a simple, reproducible, accurate, and inexpensive method for collection of the Lancet Commission on Global Surgery variables using logbooks that already exist in most hospitals in low-income countries. While some have suggested using risk-adjusted postoperative mortality rate as a more equitable variable, our data suggest that only a limited amount of risk adjustment is possible given the limited available data.

Preoperative multidisciplinary program for bariatric surgery: a proposal for the Brazilian Public Health System

ABSTRACT BACKGROUND Bariatric surgery has become the gold standard treatment for morbid obesity, but access to surgery remains difficult and low compliance to postoperative follow-up is common. To improve outcomes, enable access and optimize follow-up, we developed a multidisciplinary preoperative approach for bariatric surgery. OBJECTIVE To determine the impact of this program in the outcomes of bariatric surgery in the Brazilian public health system. METHODS A prospective evaluation of the individuals who underwent a preoperative multidisciplinary program for bariatric surgery and comparison of their surgical outcomes with those observed in the prospectively collected historical database of the individuals who underwent surgery before the beginning of the program. RESULTS There were 176 individuals who underwent the multidisciplinary program and 226 who did not. Individuals who underwent the program had significantly lower occurrence of the following variables: hospital stay; wound dehiscence; wound infection; pulmonary complications; anastomotic leaks; pulmonary thromboembolism; sepsis; incisional hernias; eventrations; reoperations; and mortality. Both loss of follow-up and weight loss failure were also significantly lower in the program group. CONCLUSION The adoption of a comprehensive preoperative multidisciplinary approach led to significant improvements in the postoperative outcomes and also in the compliance to the postoperative follow-up. It represents a reproducible and potentially beneficial approach within the context of the Brazilian public health system.

Improving Surgical and Anaesthesia Practice: Review of the Use of the WHO Safe Surgery Checklist in Felege Hiwot Referral Hospital, Ethiopia

Development of surgical and anaesthetic care globally has been consistently reported as being inadequate. The Lancet Commission on Global Surgery highlights the need for action to address this deficit. One such action to improve global surgical safety is the introduction of the WHO Surgical Checklist to Operating Rooms (OR) around the world. The checklist has a growing body of evidence supporting its ability to assist in the delivery of safe anaesthesia and surgical care. Here we report the introduction of the Checklist to a major Ethiopian referral hospital and low-resource setting and highlight the success and challenges of its implementation over a one year period. This project was conducted between July 2015 and August 2016, within a wider partnership between Felege Hiwot Hospital and The University of Aberdeen. The WHO Surgical Checklist was modified for appropriate and locally specific use within the OR of Felege Hiwot. The modified Checklist was introduced to all OR's and staff instructed on its use by local surgical leaders. Assessment of use of the Checklist was performed for General Surgical OR in three phases and Obstetric OR in two phases via observational study and case note review. Training was conduct between each phase to address challenges and promote use. Checklist utilisation in the general OR increased between Phase I and 2 from 50% to 97% and remained high at 94% in Phase 3. Between Phase I and 2 partial completion rose from 27% to 77%, whereas full completion remained unchanged (23% to 20%). Phase 3 resulted in an increase in full completion from 20% to 60%. After 1 year the least completed section was "Sign In" (53%) and "Time Out" was most completed (87%). The most poorly checked item was "Site Marked" (60%). Use of the checklist in Obstetrics OR increased between Phase I and Phase II from 50% to 100% with some improvement in partial completion (50% to 60%) and a notable increase in full completion (0% to 40%). The least completed section was "Time Out" (50%) and "Sign In" was the most completed (90%). The most poorly checked item was "Recovery Concerns" (70%). There was considerable enthusiasm for use of the checklist among staff. The greatest challenge was communication difficulties between teams and high staff turnover. This study records a locally driven, successful introduction of the WHO Surgical Safety Checklist modified for the specific locale and illustrates an increase in use of the checklist over a one year period in both General Surgical and Obstetric OR's. Local determination and ownership of the Checklist with regular intervention to promote use and train users contributed to this success.

Transanal Endoscopic Microsurgery for Patients With Rectal Tumors: A Single Institution's Experience

PURPOSE

The purpose of this study was to look at our complication rates and recurrence rates, as well as the need for further radical surgery, in treating patients with benign and early malignant rectal tumors by using transanal endoscopic microsurgery (TEM).

METHODS

Our study included 130 patients who had undergone TEM for rectal adenomas and early rectal cancer from December 2009 to December 2015 at the Department of Surgical Oncology, National Cancer Institute, Lithuania. Patients underwent digital and endoscopic evaluation with multiple biopsies. For preoperative staging, pelvic magnetic resonance imaging or endorectal ultrasound was performed. We recorded the demographics, operative details, final pathologies, postoperative lengths of hospital stay, postoperative complications, and recurrences.

RESULTS

The average tumor size was 2.8 ± 1.5 cm (range, 0.5-8.3 cm). 102 benign (78.5%) and 28 malignant tumors (21.5%) were removed. Of the latter, 23 (82.1%) were pT1 cancers and 5 (17.9%) pT2 cancers. Of the 5 patients with pT2 cancer, 2 underwent adjuvant chemoradiotherapy, 1 underwent an abdominoperineal resection, 1 refused further treatment and 1 was lost to follow up. No intraoperative complications occurred. In 7 patients (5.4%), postoperative complications were observed: urinary retention (4 patients, 3.1%), postoperative hemorrhage (2 patients, 1.5%), and wound dehiscence (1 patient, 0.8%). All complications were treated conservatively. The mean postoperative hospital stay was 2.3 days.

CONCLUSION

TEM in our experience demonstrated low complication and recurrence rates. This technique is recommended for treating patients with a rectal adenoma and early rectal cancer and has good prognosis.

Cohort profile: the Welsh Geriatric Registrar-Led Research Network (WeGeN): rationale, design and description

PURPOSE

Medical trainees are required to undertake audit and quality improvement projects. They must also have an understanding of the principles of research and are encouraged to participate in research projects. However, the constraints of time, a lack of formal training and rotation between different training posts create barriers to audit cycle completion and pursuing research. This leads to trainees being reluctant to undertake research, facilitates poor quality research and risks incomplete audit.

PARTICIPANTS

The Welsh Geriatricians Network (WeGeN) has been created with the aims of facilitating collaborative, trainee-led research within Geriatric Medicine in Wales, promoting research engagement and improving the research evidence base for older patients. By coordinating collaborative research projects across different sites within Wales, trainees continue existing projects at new sites, allowing completion of projects and establishing the long-term infrastructure and experienced personnel needed for high-quality research data to be gathered.

FINDINGS

WeGeN has facilitated 4 national audits, all of which are intended for peer review publication. The first project considers the service provision for the older person in the emergency department, the second Parkinson's disease, the third reviews delirium management and the fourth project considers epidemiology of surgical disease in older people.

FUTURE PLANS

The objective of this project is to further establish and develop WeGeN as a group which facilitates high-quality research and provides the opportunity for geriatric trainees to engage in research activity. It is anticipated that the establishment of this research platform will provide a blueprint for the development of other such networks in the UK and beyond.

Laparoscopic vs. open surgery for the treatment of iatrogenic colonoscopic perforations: a systematic review and meta-analysis

AIMS

Iatrogenic colonoscopy perforations (ICP) are a rare but severe complication of diagnostic and therapeutic colonoscopies. The present systematic review and meta-analysis aims to investigate the operative and post-operative outcomes of laparoscopy vs. open surgery performed for the management of ICP.

METHODS

A literature search was carried out on Medline, EMBASE, and Scopus databases from January 1990 to June 2016. Clinical studies comparing the outcomes of laparoscopic and open surgical procedures for the treatment for ICP were retrieved and analyzed.

RESULTS

A total of 6 retrospective studies were selected, including 161 patients with ICP who underwent surgery. Laparoscopy was used in 55% of the patients, with a conversion rate of 10%. The meta-analysis shows that the laparoscopic approach was associated with significantly fewer post-operative complications compared to open surgery (18.2% vs. 53.5% respectively; Relative risk, RR: 0.32 [95%CI: 0.19-0.54; p < 0.0001; I2 = 0%]) and shorter hospital stay (mean difference -5.35 days [95%CI: -6.94 to -3.76; p < 0.00001; I2 = 0%]). No differences between the two surgical approaches were observed for postoperative mortality, need of re-intervention, and operative time.

CONCLUSION

The present study highlights the outcomes of the surgical management of an endoscopic complication that is not yet considered in clinical guidelines. Based on the current available literature, the laparoscopic approach appears to provide better outcomes in terms of postoperative complications and length of hospital stay than open surgery in the case of ICP surgical repair. However, the creation of large prospective registries of patients with ICP would be a step forward in addressing the lack of evidence concerning the surgical treatment of this endoscopic complication.

Anti-inflammatory and immune regulatory effects of acupuncture after craniotomy: study protocol for a parallel-group randomized controlled trial

BACKGROUND

Despite recent advances in the medical and surgical fields, complications such as infection, pneumonia, or brain swelling may occur after a craniotomy. In some patients, perioperative antibiotic prophylaxis causes adverse effects such as itching, rash, or digestive conditions. Certain patients still develop infections severe enough to require a repeat operation despite antibiotic prophylaxis. Acupuncture has been used to treat inflammatory conditions, and many basic and clinical studies have provided evidence of its anti-inflammatory and immune regulatory effects. The aim of this study is to explore the effects of acupuncture on inflammation and immune function after craniotomy.

METHODS

This trial will be a single-center, parallel-group clinical trial. Forty patients who underwent craniotomy for an unruptured aneurysm, facial spasm, or a brain tumor will be allocated to either the study or the control group. The study group will receive conventional management as well as acupuncture, electroacupuncture, and intradermal acupuncture, which will start within 48 h of the craniotomy. The patients will receive a total of six sessions within 8 days. The control group will only receive conventional management. The primary outcome measure will be the C-reactive protein levels, while the secondary outcomes will be the serum erythrocyte sedimentation rate and the tumor necrosis factor-α, interleukin (IL)-1β, and IL-6 levels measured at four different time points: within 48 h prior to the craniotomy and on days 2, 4, and 7 after surgery. The presence of fever and infection, the use of additional antibiotics, the presence of infection, including pneumonia or urinary tract infection, and safety will also be investigated.

DISCUSSION

In this trial, we will observe whether acupuncture has anti-inflammatory and immune regulatory effects after a craniotomy. If our study yields positive results and a placebo-controlled study also finds favorable results following our study, acupuncture could be recommended as an adjunctive therapy after a craniotomy.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02761096 . Registered on 27 April 2016.

Methylene Blue Effectiveness as Local Analgesic after Anorectal Surgery: A Literature Review

BACKGROUND

Methylene blue (MB) has been found to have unique analgesic property through temporary disruption of sensory nerve conduction. In anorectal surgery, MB is widely used as a biologic stain but the analgesic effect has never been studied. Thus, a literature review completed with critical appraisal is required to find out its efficacy.

METHODS

A review has been run to find out its efficacy. Literature search proceeded in database sites, namely, PubMed, EBSCO, Cochrane, Wiley, and ProQuest using the following keywords: "anorectal" OR "hemorrhoid" OR "anal fistula" OR "anal fissure" OR "anal abscess" OR "anal pruritus" AND "methylene blue" AND "analgesic"; then the critical appraisal and its implication were discussed.

RESULT

There were 491 articles in full text found, and four studies met the inclusion criteria. Two studies were focused on the evaluation of VAS in hemorrhoid surgery whereas the rest were focused on the evaluation of symptom score in anal pruritus.

CONCLUSIONS

A study with level of evidence 2 on VAS showed the efficacy. The rest showed insufficient evidence due to variations of anorectal surgery and the methods and techniques of MB application. A further prospective clinical study is required.

[Not Available]

Zusammenfassung. Der auf Höhe der Linea dentata gelegene Corpus cavernosum recti spielt eine tragende Rolle bei der Regulierung der Feinkontinenz. Kommt es zu einer pathologischen Vergrösserung des Corpus cavernosum verbunden mit Symptomen, spricht man von einem Hämorrhoidalleiden. Das Hämorrhoidalleiden ist eine Volkskrankheit mit einer Inzidenz von ca. 40 %, wobei die Rate an Selbsttherapien hoch ist. Im klinischen Alltag fällt der stadienadaptierten Therapie eine wichtige Rolle zu: Hämorrhoiden Grad I sind die Domäne der konservativen Therapie, Hämorrhoiden Grad II können in Abhängigkeit der Schwere der Symptome konservativ oder operativ angegangen werden. Hämorrhoiden Grad III und Grad IV sollten einer Operation zugeführt werden.

Asymptomatic primary tumour in incurable metastatic colorectal cancer: is there a role for surgical resection prior to systematic therapy or not?

INTRODUCTION

The role of the resection of asymptomatic primary colorectal cancer in patients with incurable disease is questionable.

AIM

To evaluate the impact of the resection of asymptomatic primary tumour on overall survival in patients with unresectable distant metastases.

MATERIAL AND METHODS

Patients treated in the National Cancer Institute, Lithuania, in the period 2008-2012, were selected retrospectively. The main inclusion criteria were: metastatic colorectal cancer (mCRC), endoscopically and histologically confirmed adenocarcinoma, without any symptoms for urgent operation, and at least one cycle of palliative chemotherapy administered. Information on patients' age, gender, tumour histology, localization of the tumour, regional lymph node involvement, number of metastatic sites, surgery and systemic treatment was collected prospectively. Eligible patients for the study were divided into two groups according to the initial treatment - surgery (patients who underwent primary tumour resection) and chemotherapy (patients who received chemotherapy without surgery). The impact of initial treatment strategy, tumour size and site, regional lymph nodes, grade of differentiation of adenocarcinoma and application of biotherapy on overall cumulative survival was estimated using the Kaplan-Meier method. To compare survival between groups the log-rank test was used. Cox regression analysis was employed to assess the effects of variables on patient survival.

RESULTS

The study group consisted of 183 patients: 103 men and 80 women. The median age was 66 years (range: 37-91). There were no notable imbalances with regard to age, gender, number of metastatic sites, metastases (such as pulmonary, peritoneal, liver, metastases into non-regional lymph nodes and other metastases), the number of received cycles of chemotherapy, first line chemotherapy type or biological therapy. Only 27 (14.8%) patients received biological therapy and the majority of them (n = 25, 92.6%) were treated with bevacizumab. For surgically treated patients 1-year survival was 71.2% (95% CI: 62.1-78.5) and 5-year survival was 4.0% (95% CI: 1.0-10.5). In the chemotherapy group, survival rates were lower - 43.9% (95% CI: 31.4-55.7) and 1.7% (95% CI: 0.1-8.1), respectively. Better survival rates were in the palliative surgery group. Multivariate analysis using the Cox proportional hazards model revealed that the initial palliative surgery and the application of biological therapy were statistically significant independent prognostic factors for survival.

CONCLUSIONS

Our findings suggest that palliative resectional surgery for the primary tumour in patients with incurable mCRC improves survival. Of course, one can argue that patients in the surgery group were "less problematic". Prospective randomized trials are needed to delineate precisely the role of palliative surgery of the primary tumour in these patients.

Predictors of Morbidity and Mortality After Surgery for Intestinal Perforation

Purpose

An intestinal perforation is a rare condition, but has a high mortality rate, even after immediate surgical intervention. The clinical predictors of postoperative morbidity and mortality are still not well established, so this study attempted to identify risk factors for postoperative morbidity and mortality after surgery for an intestinal perforation.

Methods

We retrospectively analyzed the cases of 117 patients who underwent surgery for an intestinal perforation at a single institution in Korea from November 2008 to June 2014. Factors related with postoperative mortality at 1 month and other postoperative complications were investigated.

Results

The mean age of enrolled patients was 66.0 ± 15.8 years and 66% of the patients were male. Fifteen patients (13%) died within 1 month after surgical treatment. Univariate analysis indicated that patient-related factors associated with mortality were low systolic and diastolic blood pressure, low serum albumin, low serum protein, low total cholesterol, and high blood urea nitrogen; the surgery-related factor associated with mortality was feculent ascites. Multivariate analysis using a logistic regression indicated that low systolic blood pressure and feculent ascites independently increased the risk for mortality; postoperative complications were more likely in both females and those with low estimated glomerular filtration rates and elevated serum C-reactive protein levels.

Conclusion

Various factors were associated with postoperative clinical outcomes of patients with an intestinal perforation. Morbidity and mortality following an intestinal perforation were greater in patients with unstable initial vital signs, poor nutritional status, and feculent ascites.

GlobalSurg Collaborative. Determinants of morbidity and mortality following emergency abdominal surgery in children in low-income and middle-income countries

BACKGROUND

Child health is a key priority on the global health agenda, yet the provision of essential and emergency surgery in children is patchy in resource-poor regions. This study was aimed to determine the mortality risk for emergency abdominal paediatric surgery in low-income countries globally.

METHODS

Multicentre, international, prospective, cohort study. Self-selected surgical units performing emergency abdominal surgery submitted prespecified data for consecutive children aged <16 years during a 2-week period between July and December 2014. The United Nation's Human Development Index (HDI) was used to stratify countries. The main outcome measure was 30-day postoperative mortality, analysed by multilevel logistic regression.

RESULTS

This study included 1409 patients from 253 centres in 43 countries; 282 children were under 2 years of age. Among them, 265 (18.8%) were from low-HDI, 450 (31.9%) from middle-HDI and 694 (49.3%) from high-HDI countries. The most common operations performed were appendectomy, small bowel resection, pyloromyotomy and correction of intussusception. After adjustment for patient and hospital risk factors, child mortality at 30 days was significantly higher in low-HDI (adjusted OR 7.14 (95% CI 2.52 to 20.23), p<0.001) and middle-HDI (4.42 (1.44 to 13.56), p=0.009) countries compared with high-HDI countries, translating to 40 excess deaths per 1000 procedures performed.

CONCLUSIONS

Adjusted mortality in children following emergency abdominal surgery may be as high as 7 times greater in low-HDI and middle-HDI countries compared with high-HDI countries. Effective provision of emergency essential surgery should be a key priority for global child health agendas.

TRIAL REGISTRATION NUMBER

NCT02179112; Pre-results.