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

PErioperative respiratory care aNd outcomes for patients underGoing hIgh risk abdomiNal surgery (PENGUIN): a randomised international internal pilot trial

Background

Infections are a common complication of abdominal surgery in low- and middle-income countries (LMICs). The role of a high fraction of inspired oxygen (FiO2) and chlorhexidine mouthwash in preventing post-operative infections is unconfirmed.

Methods

Internal pilot phase of an international outcome assessor-blinded, 2x2 factorial randomised trial of patients aged ≥10-years undergoing midline laparotomy in LMIC hospitals. The main trial objectives are to compare the clinical effectiveness of preoperative 0.2% chlorhexidine mouthwash in preventing pneumonia versus no mouthwash, and 80-100% perioperative FiO2 to prevent surgical site infection (SSI) versus 21-35% FiO2. This 12-month internal pilot assessed feasibility of hospital site opening, patient recruitment, intervention adherence, patient follow-up and safety. Patients were randomised in a 1:1:1:1 ratio to the four intervention group combinations and followed up for 30 days.

Results

We recruited 927 patients from seven hospitals in India and South Africa over 12 months from November 2020. There were 907 adults (97.8%) and 20 children aged ten or over (2.2%): 89/927 (9.6%) patients died. Site opening reached 70% of our target (7/10) hospitals, and patient recruitment 107% (927/870). 917/927 (99%) patients in the mouthwash arm, and 840/927 (91%) patients in the oxygen arm received the allocated intervention. Lower adherence to the oxygen intervention related mainly to clinically necessary FiO2 increases in the 21-35% FiO2 arm. 30-day follow-up was completed appropriately for 924/927 (99%) patients. and was performed by a masked assessor for all patients. There were no reported safety events.

Conclusion

This pilot showed the feasibility and safety of a major phase III trial in post-operative infection prevention in LMICs.

Trial registration

ClinicalTrials.gov NCT04256798.

Risk-Adjustment of Perioperative Mortality Rate Measurement in a Low-Income Country

BACKGROUND

The health care systems in low-income countries have extremely limited capacity to treat surgical diseases. The perioperative mortality rate has been suggested as a key quality metric to guide the expansion of care, but there is little information on how to risk-adjust this outcome measure.

METHODS

We did a 42-month observational cohort study of surgical operations at a Ugandan secondary referral hospital. We examined factors associated with in-hospital 30-day perioperative mortality outcomes. The aim of the study was to suggest a suitable indicator metric for comparative health service research in low-income countries.

RESULTS

The 30-day perioperative mortality rate was 5.3 % (n = 381/7170). The adjusted odds ratios (95% confidence interval) of variables associated with mortality were as follows: procedure (P < .001; laparotomy 2.6 [1.6, 4.3], P < .001; cranial surgery 2.8 [1.6, 4.9], P < .001); American Society of Anesthesiologists (ASA) rating 3.1 (2.6, 3.6), P < .001; HIV serostatus (P < .001; positive 2.7 [1.5, 4.8], P < .001); procedure urgency (urgent/emergent) 1.7 (1.2, 2.3), P = .003; home district location (P = .015; distant referral 1.4 [1.0, 1.9], P = .027); and age decile 1.1 (1.0,1.2, P = .001). Laparotomy was the commonest procedure performed (n = 2361) and was associated with 56.3% (n = 216/381) of deaths.

CONCLUSIONS

Laparotomy had a strong independent association with mortality at a Ugandan secondary hospital. The laparotomy perioperative mortality rate may be a suitable outcome measure for comparative health service research in low-income countries.

Incidence and predictors of perioperative mortality in Ethiopia: a systematic review and meta-analysis

INTRODUCTION

The Lancet Commission on Global Surgery highlights perioperative mortality rate (POMR) as a key indicator of a nation's surgical system effectiveness. While POMR is often measured in high-income countries, it is less studied in low- and middle-income countries (LMICs). This study aims to assess the POMR and its predictors in Ethiopia.

METHODS

We conducted a thorough literature search across PubMed/MEDLINE, Embase, Web of Science, Scopus, and Google Scholar for studies from Ethiopia between 2019 and 2023 reporting POMR for various surgical procedures. Data were extracted in duplicate from eligible studies. We used random-effects meta-analysis to pool estimates of POMR and its predictors.

RESULTS

The meta-analysis revealed a POMR of 5.36%. Identified predictors of perioperative mortality in Ethiopia included older age, comorbidities, ICU admission, and an ASA physical status classification of III or higher and emergency surgeries.

CONCLUSION

Ethiopia's perioperative mortality rate is significantly high. Improving surgical care quality and safety, along with expanding access to surgical services, is crucial for bettering surgical outcomes in the country.

Morbidity and Mortality Following Surgery for Pancreatic Cancer in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis

BACKGROUND AND OBJECTIVES

Measuring postoperative outcomes after complex cancer operations such as pancreatectomy is vital to improve cancer surgery in low- and middle-income countries (LMICs); however, such data is often limited. This study aimed to review existing research and obtain baseline estimates for postoperative mortality and morbidity after pancreatic cancer surgery in LMICs.

METHODS

PubMed, Embase, Web of Science Core Collection, and Global Index Medicus were systematically searched for original articles published between January 2005 and May 2022. LMICs based studies reporting postoperative mortality, morbidity, and/or length of stay of patients with primary pancreatic tumors undergoing pancreaticoduodenectomy and/or distal pancreatectomy were included.

RESULTS

Of 18 344 unique titles and abstracts retrieved, 114 studies met the inclusion criteria. Of these, 51 "good" quality studies comprising 7528 patients were included in the meta-analyses. Pooled estimates for pancreatic fistula were 16.6% (95% CI 14.0-19.7, p < 0.001); 16.0% (95% CI 11.1-22.5, p < 0.001) for Clavien-Dindo grade 3 and 4 complications; 13.4% (95% CI 9.8-17.9, p < 0.001) for wound infection; and 4.4% (95% CI 3.3-5.7, p < 0.001) for postoperative mortality.

CONCLUSION

This is the first systematic review and meta-analysis examining surgical complications after pancreatic surgery in LMICs. We highlight a lack of data and the need to further evaluate surgical outcomes in LMICs.

Global collaboration between platform trials in surgery and anaesthesia

Large, randomised trials are the bedrock of evidence-based medicine, but the resources required to complete such trials greatly limit the number of important clinical questions that can be addressed within a reasonable period of time. Adaptive platform trials can identify effective, ineffective, or harmful treatments faster. These trials have been shown to deliver rapid evidence through the COVID-19 pandemic and are now being adopted across surgery and anaesthesia, with many opportunities for surgeons, anaesthetists, and other perioperative physicians to conduct and collaborate in platform trials.

The global, regional, and national burden of paralytic ileus and intestinal obstruction, 1990 to 2021: a cross-sectional analysis from the 2021 global burden of disease study

BACKGROUND

Paralytic ileus and intestinal obstruction (PIAIO) pose significant public health concerns, given the notable scarcity of current research on their disease burden and trends. This study evaluated the global burden of PIAIO from 1990 to 2021 and forecasted their future burden over the next three decades.

METHODS

Using the latest data from Global Burden of Disease Study (GBD) 2021, we obtained the prevalence, incidence, mortality and disability adjusted life years (DALYs) data for these conditions, along with their corresponding age-standardized rate (ASR) indicators. Data were stratified by time, location, age and socio-demographic index (SDI). This study employed comprehensive analyses over 32 years (1990-2021) to reveal trends in PIAIO, using advanced statistical methods including estimated Annual percentage change (EAPC), Joinpoint regression, health inequity analysis (slope index and concentration index), decomposition analysis, frontier analysis and predictive modeling (Nordpred method).

RESULTS

In 2021, the global age-standardized rates for prevalence (ASPR), incidence (ASIR), mortality (ASMR), and DALYs (ASDR) were 7.38 (95%UI: 7.12-7.65), 191.92 (95%UI: 185.41-198.80), 2.88 (95%UI: 2.52-3.22), and 84.49 (95%UI: 72.58-94.16), respectively. High SDI regions exhibited high ASPR, high ASIR, but low ASDR and ASMR. Males generally exhibited higher prevalence and incidence rates across most age groups, while females showed higher mortality and DALY rates in specific age brackets. The epidemiological indicators of the age group under 5 years old and the elderly are relatively high. The joinpoint regression analysis indicated fluctuating increases in ASPR and ASIR, and nearly linear declines in ASMR and ASDR over the past 32 years. Health inequity analyses of the slope indices of ASPR and ASIR suggested an exacerbation of inequality in certain health indicators over the past 32 years, while those of ASMR and ASDR indicate potential improvements in inequality in certain health outcomes. Concentration index analysis confirms a significant reduction in inequality for ASPR and ASIR, with marginal changes for ASMR and ASDR, highlighting persistent health disparities in certain areas despite overall improvements. The decomposition analysis of global and across SDI regions indicated that population and aging have increased the DALYs burden, while epidemiological changes have reduced the disease burden. The frontier analysis suggested greater potential for improvement in low SDI regions. Nordpred predictive analysis forecasts a slight increase in ASPR and ASIR by 2050, with a significant in ASMR.

CONCLUSION

PIAIO represent substantial global health and economic challenges. Anticipated population growth and aging will exacerbate burdens, highlighting the urgency of addressing critical need for targeted prevention and control strategies. Health system managers should develop robust plans to mitigate these escalating health challenges.

Assessing the continuum of care in Sub-Saharan African hospitals performing surgery for breast cancer: a secondary analysis of the GlobalSurg 3 study

BACKGROUND

While breast cancer incidence rates in Sub-Saharan Africa (SSA) are among the lowest worldwide, mortality rates remain among the highest, reflecting particularly poor survival. Only a few studies in SSA have investigated the capabilities of treatment services to adequately provide a continuum of care for breast cancer. Our aim was to assess the availability of diagnostic facilities and adjuvant therapies in hospitals performing breast cancer surgery in SSA.

METHODS

We performed a secondary analysis of the GlobalSurg3 study data collected in the SSA region. The GlobalSurg 3 study is a multicenter, international, prospective, observational study of hospitals providing surgical services for cancer patients (including breast cancer) around the world. A total of 47 hospitals from 15 SSA countries and 43 cities were included between April 1, 2018, and Jan 31, 2019.

RESULTS

One-third of hospitals covered a population greater than two million (n = 17; 36.2%). Ultrasound was available in all hospitals; however, it was not consistently functional in 11 hospitals (23.4%). Only half of the included hospitals (n = 26, 55.3%) had access to a full-time pathologist, whilst the multidisciplinary team (MDT) approach was absent in 42.4% of hospitals. Radiotherapy equipment was only available in nine hospitals (19.1%). Only half of the hospitals (n = 25, 53.1%) had chemotherapy drugs available on site. In nine hospitals (19.1%), patients had to travel more than 50 km to access chemotherapy drugs.

CONCLUSIONS

Outcomes for breast cancer patients in SSA cannot be improved without significant investments in pathology, surgical and oncological treatment pathways to provide timely diagnostic and effective treatment.

Health systems strengthening through surgical and perioperative care pathways: a changing paradigm

Global health has traditionally focused on the primary health development with disease-specific focus such as HIV, malaria and non-communicable diseases (NCDs). As such, surgery has traditionally been neglected in global health as investment in them is often expensive, relative to these other priorities. Therefore, efforts to improve surgical care have remained on the periphery of initiatives in health system strengthening. However, today, many would argue that global health should focus on universal health coverage with primary health and surgery and perioperative care integrated as a part of this. In this article, we discuss the past developments and future-looking solutions on how surgery can contribute to the delivery of effective and equitable healthcare across the world. These include bidirectional integration of surgical and chronic disease pathways and better understanding financing initiatives. Specifically, we focus on access to safe elective and emergency surgery for NCDs and an integrated approach towards the rising multimorbidity from chronic disease in the population. Underpinning these, data-driven solutions from high-quality research from clinical trials and cohort studies through established surgical research networks are needed. Although challenges will remain around financing, we propose that development of surgical services will strengthen and improve performance of whole health systems and contribute to improvement in population health across the world.

Acute Appendicitis Management in Patients Aged Above 40 Years During the COVID-19 Pandemic: A Retrospective Study With Four Years of Follow-Up

Background The COVID-19 pandemic led many units to increase their utilization of nonoperative management (NOM) of acute appendicitis, with the literature showing its non-inferiority when compared to operative management (OM). Therefore, we compared NOM to OM against standard guidelines in order to ascertain the effectiveness of NOM. Primary outcomes were rates of admission, complications, hospital length of stay (LOS), and the incidence of colonic malignancy following NOM upon subsequent bowel evaluation using colonoscopy and/or computed tomography (CT) scan. Methods This was a retrospective observational study done on patients who were admitted with acute appendicitis from January 2020 to January 2022 at Wirral University Teaching Hospital, UK. Data was electronically collected from medical records. Inclusion criteria were patients aged 40 years and above, admitted with a diagnosis of acute appendicitis using a CT scan, and who underwent either OM or NOM. Exclusion criteria were patients below 40 years old or not diagnosed with acute appendicitis. Results This study included 211 cases of acute appendicitis (female to male: 110:101), with a median age of 60. One hundred and twenty-five (60%) patients were managed operatively, while 86 cases (40%) were managed by NOM. All of the cases were diagnosed using a CT scan. The mean LOS for operative and non-operative cases were 4.77 and 4.89 days, respectively. When readmission days were added over the following three years, adjusted LOS was 5.35 days for operative cases, in comparison to 10.86 days for NOM. Forty-five percent of NOM cases had at least one episode of readmission, with 37% of them being in the first year. We found six cases of malignancy in the NOM cohort, none of which were detected on colonoscopy following discharge. Conclusion NOM is associated with increased LOS and increased readmission rates, and 44% of cases eventually required appendicectomy.

Mechanisms and causes of death after abdominal surgery in low-income and middle-income countries: a secondary analysis of the FALCON trial

BACKGROUND

Death after surgery is devasting for patients, families, and communities, but remains common in low-income and middle-income countries (LMICs). We aimed to use high-quality data from an existing global randomised trial to describe the causes and mechanisms of postoperative mortality in LMICs. To do so, we developed a novel framework, learning from both existing classification systems and emerging insights during data analysis.

METHODS

This study was a preplanned secondary analysis of the FALCON trial in 54 hospitals across seven LMICs (Benin, Ghana, India, Mexico, Nigeria, Rwanda, and South Africa). FALCON was a pragmatic, 2 × 2 factorial, randomised controlled trial that compared the effectiveness of two types of interventions for skin preparation (10% aqueous povidone-iodine vs 2% alcoholic chlorhexidine) and sutures (triclosan-coated vs uncoated). Patients who did not have surgery or were lost to follow-up were excluded (n=231). The primary outcomes of the present analysis were the mechanism and cause of death within 30-days of surgery, determined using a modified verbal autopsy strategy from serious adverse event reports. Factors associated with mortality were explored in a mixed-effects Cox proportional hazards model. The FALCON trial is registered with ClinicalTrials.gov, NCT03700749.

FINDINGS

This preplanned secondary analysis of the FALCON trial included 5558 patients who underwent abdominal surgery, of whom 4248 (76·4%) patients underwent surgery in tertiary, referral centres and 1310 (23·6%) underwent surgery in primary referral (ie, district or rural) hospitals. 3704 (66·7%) of 5558 surgeries were emergent. 306 (5·5%) of 5558 patients died within 30 days of surgery. 226 (74%) of 306 deaths were due to circulatory system failure, which included 173 (57%) deaths from sepsis and 29 (9%) deaths from hypovolaemic shock including bleeding. 47 (15%) deaths were due to respiratory failure. 60 (20%) of 306 patients died without a clear cause of death: 45 (15%) patients died with sepsis of unknown origin and 15 (5%) patients died of an unknown cause. 46 (15%) of 306 patients died within 24 h, 111 (36%) between 24 h and 72 h, 57 (19%) between >72 h and 168 h, and 92 (30%) more than 1 week after surgery. 248 (81%) of 306 patients died in hospital and 58 (19%) patients died out of hospital. The adjusted Cox regression model identified age (hazard ratio 1·01, 95% CI 1·01-1·02; p<0·0001), ASA grade III-V (4·93, 3·45-7·03; p<0·0001), presence of diabetes (1·47, 1·04-2·41; p=0·033), being an ex-smoker (1·59, 1·10-2·30; p=0·013), emergency surgery (2·08, 1·45-2·98; p<0·0001), cancer (1·98, 1·42-2·76; p<0·0001), and major surgery (3·94, 2·30-6·75; p<0·0001) as risk factors for postoperative mortality INTERPRETATION: Circulatory failure leads to most deaths after abdominal surgery, with sepsis accounting for almost two-thirds. Variability in timing of death highlights opportunities to intervene throughout the perioperative pathway, including after hospital discharge. A high proportion of patients without a clear cause of death reflects the need to improve capacity to rescue and cure by strengthening perioperative systems.

FUNDING

National Institute for Health and Care Research Global Health Research Unit.

Preoperative mortality risk evaluation in abdominal surgical emergencies: development and internal validation of the NDAR score from a national multicenter audit in Senegal

INTRODUCTION

Abdominal surgical emergencies have a high mortality rate. Effective management primarily relies on the early identification of patients at high risk of postoperative complications. The objective of our study was to determine the prognostic factors associated with poor outcomes from abdominal surgical emergencies in Senegal and to establish a predictive score for mortality for preoperative risk evaluation (NDAR (New Death Assessment Risk) score).

METHODOLOGY

This was a retrospective national cross-sectional study conducted over one year in 14 regions of Senegal. Adult patients (aged > 15 years) who presented with a traumatic or non-traumatic abdominal surgical emergency were included. The studied variables included clinical and paraclinical data. The variable of interest was death within 30 days of the surgery. Logistic regression was used to identify the factors independently associated with mortality. Risk factors identified after logistic regression analysis were weighted using odds ratio (OR) values rounded to the nearest whole number. The predictive capacity of the score was evaluated by analyzing the ROC (Receiver Operating Characteristic) curve based on the area under the curve (AUC).

RESULTS

A total of 1114 patient records were included, with a mortality rate of 4.4%. Diagnoses were observed in patients included appendicitis in 39.8% of cases (n = 444), followed by peritonitis in 22.3% (n = 249), intestinal obstruction in 18.5% (n = 205), strangulated hernias in 10.5% (n = 117), and abdominal trauma in 6.1%. Logistic regression, established the following scores: age > 40 years (score 2), ASA status grade 2 or higher (score 1), presence of a positive QSIRS score (score 2), diagnosis of peritonitis (score 2), diagnosis of intestinal obstruction (score 1), and the presence of intestinal necrosis (score 3). The score is positive if the total is strictly greater than 5, indicating a 17.7% risk of mortality. This score had a high predictive capacity with an AUC of 0.7397.

CONCLUSION

This study enabled the establishment of a score that allows for the early identification of at-risk patients, even in constrained resource settings, facilitating appropriate perioperative management and timely surgical intervention to reduce the risk of complications. This approach, focused on early recognition of high-risk patients, is crucial for improving clinical outcomes in abdominal surgical emergencies.

A Retrospective Study of Routine Preoperative Blood Grouping and Saving in Laparoscopic Surgeries: A Minimally Utilized Expenditure

Introduction Patients scheduled for laparoscopic cholecystectomy and laparoscopic appendicectomy typically undergo routine preoperative blood grouping and saving (G&S). Despite the low incidence of blood transfusion in this context, the acquisition and processing of G&S samples incur a cost of £31 ($40) per sample. This study aims to review blood transfusion usage in these procedures to determine whether routine G&S sampling is clinically necessary or represents an avoidable expense. Methods A retrospective case note analysis was conducted on patients who underwent laparoscopic cholecystectomy and laparoscopic appendicectomy from January 2019 to June 2020. Collected data included the timing of G&S, preoperative and postoperative hemoglobin levels, timing of blood transfusions, and the number of units transfused. Results Six hundred and thirteen patients were involved in the study. Among the 323 patients who had laparoscopic cholecystectomy, 256 (78.8%) underwent preoperative G&S sampling. Of the 290 patients who had laparoscopic appendicectomy, 190 (65.5%) received preoperative G&S sampling. Notably, none of the 613 patients required a blood transfusion within 30 days of their surgery. The total cost of G&S for the cohort amounted to £22,196 ($28,425). Conclusions The findings suggest that routine G&S sampling is an unnecessary expenditure for patients undergoing elective laparoscopic appendicectomy or cholecystectomy. It is recommended that G&S sampling be reserved for high-risk groups to optimize resource allocation and reduce unnecessary costs.

Multicenter validation of an artificial intelligence (AI)-based platform for the diagnosis of acute appendicitis

BACKGROUND

The current scores used to help diagnose acute appendicitis have a "gray" zone in which the diagnosis is usually inconclusive. Furthermore, the universal use of CT scanning is limited because of the radiation hazards and/or limited resources. Hence, it is imperative to have an accurate diagnostic tool to avoid unnecessary, negative appendectomies.

METHODS

This was an international, multicenter, retrospective cohort study. The diagnostic accuracy of the artificial intelligence platform was assessed by sensitivity, specificity, negative predictive value, the area under the receiver curve, precision curve, F1 score, and Matthews correlation coefficient. Moreover, calibration curve, decision curve analysis, and clinical impact curve analysis were used to assess the clinical utility of the artificial intelligence platform. The accuracy of the artificial intelligence platform was also compared to that of CT scanning.

RESULTS

Two data sets were used to assess the artificial intelligence platform: a multicenter real data set (n = 2,579) and a well-qualified synthetic data set (n = 9736). The platform showed a sensitivity of 92.2%, specificity of 97.2%, and negative predictive value of 98.7%. The artificial intelligence had good area under the receiver curve, precision, F1 score, and Matthews correlation coefficient (0.97, 86.7, 0.89, 0.88, respectively). Compared to CT scanning, the artificial intelligence platform had a better area under the receiver curve (0.92 vs 0.76), specificity (90.9 vs 53.3), precision (99.8 vs 98.9), and Matthews correlation coefficient (0.77 vs 0.72), comparable sensitivity (99.2 vs 100), and lower negative predictive value (67.6 vs 99.5). Decision curve analysis and clinical impact curve analysis intuitively revealed that the platform had a substantial net benefit within a realistic probability range from 6% to 96%.

CONCLUSION

The current artificial intelligence platform had excellent sensitivity, specificity, and accuracy exceeding 90% and may help clinicians in decision making on patients with suspected acute appendicitis, particularly when access to CT scanning is limited.

Trends and levels of the global, regional, and national burden of appendicitis between 1990 and 2021: findings from the Global Burden of Disease Study 2021

BACKGROUND

Appendicitis is a common surgical emergency that poses a large clinical and economic burden. Understanding the global burden of appendicitis is crucial for evaluating unmet needs and implementing and scaling up intervention services to reduce adverse health outcomes. This study aims to provide a comprehensive assessment of the global, regional, and national burden of appendicitis, by age and sex, from 1990 to 2021.

METHODS

Vital registration and verbal autopsy data, the Cause of Death Ensemble model (CODEm), and demographic estimates from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) were used to estimate cause-specific mortality rates (CSMRs) for appendicitis. Incidence data were extracted from insurance claims and inpatient discharge sources and analysed with disease modelling meta-regression, version 2.1 (DisMod-MR 2.1). Years of life lost (YLLs) were estimated by combining death counts with standard life expectancy at the age of death. Years lived with disability (YLDs) were estimated by multiplying incidence estimates by an average disease duration of 2 weeks and a disability weight for abdominal pain. YLLs and YLDs were summed to estimate disability-adjusted life-years (DALYs).

FINDINGS

In 2021, the global age-standardised mortality rate of appendicitis was 0·358 (95% uncertainty interval [UI] 0·311-0·414) per 100 000. Mortality rates ranged from 1·01 (0·895-1·13) per 100 000 in central Latin America to 0·054 (0·0464-0·0617) per 100 000 in high-income Asia Pacific. The global age-standardised incidence rate of appendicitis in 2021 was 214 (174-274) per 100 000, corresponding to 17 million (13·8-21·6) new cases. The incidence rate was the highest in high-income Asia Pacific, at 364 (286-475) per 100 000 and the lowest in western sub-Saharan Africa, at 81·4 (63·9-109) per 100 000. The global age-standardised rates of mortality, incidence, YLLs, YLDs, and DALYs due to appendicitis decreased steadily between 1990 and 2021, with the largest reduction in mortality and YLL rates. The global annualised rate of decline in the DALY rate was greatest in children younger than the age of 10 years. Although mortality rates due to appendicitis decreased in all regions, there were large regional variations in the temporal trend in incidence. Although the global age-standardised incidence rate of appendicitis has steadily decreased between 1990 and 2021, almost half of GBD regions saw an increase of greater than 10% in their age-standardised incidence rates.

INTERPRETATION

Slow but promising progress has been observed in reducing the overall burden of appendicitis in all regions. However, there are important geographical variations in appendicitis incidence and mortality, and the relationship between these measures suggests that many people still do not have access to quality health care. As the incidence of appendicitis is rising in many parts of the world, countries should prepare their health-care infrastructure for timely, high-quality diagnosis and treatment. Given the risk that improved diagnosis may counterintuitively drive apparent rising trends in incidence, these efforts should be coupled with improved data collection, which will also be crucial for understanding trends and developing targeted interventions.

FUNDING

Bill and Melinda Gates Foundation.

Global evaluation and outcomes of cholecystectomy: protocol for a multicentre, international, prospective cohort study (GlobalSurg 4)

INTRODUCTION

Cholecystectomy is one of the most common operations performed worldwide. Although laparoscopic surgery has been the 'gold-standard' approach for this operation, there is a paucity of global evidence around the variations of safe provision of cholecystectomy, including low-income and middle-income countries. This international collaborative study will allow contemporaneous data collection on the quality of cholecystectomies using measures covering infrastructure, care processes and outcomes, with the primary aim define the global variation in compliance with preoperative, intraoperative and postoperative audit standards.

METHODS AND ANALYSIS

Global Evaluation of Cholecystectomy Knowledge and Outcomes is a prospective, international, multicentre, observational cohort study delivered by the GlobalSurg Collaborative. Consecutive patients undergoing cholecystectomy between 31 July 2023 and 19 November 2023 will be recruited, with follow-up at 30 days and 1-year postoperatively. The study will be undertaken at any hospital providing emergency or elective surgical services for biliary disease. The primary endpoint of this study is compliance with preoperative, intraoperative and postoperative audit standards. Secondary outcomes include rates of 30-day complications, achievement of critical view of safety and rates of gallbladder cancer.

ETHICS AND DISSEMINATION

This project will not affect clinical practice and has been classified as clinical audit following research ethics review at University Hospital Birmingham NHS Trust. The protocol will be disseminated through the international GlobalSurg and CovidSurg network.

TRIAL REGISTRATION NUMBER

NCT06223061.

NIHR Global Health Research Unit on Global Surgery. Access to and quality of elective care: a prospective cohort study using hernia surgery as a tracer condition in 83 countries

BACKGROUND

Timely and safe elective health care facilitates return to normal activities for patients and prevents emergency admissions. Surgery is a cornerstone of elective care and relies on complex pathways. This study aimed to take a whole-system approach to evaluating access to and quality of elective health care globally, using inguinal hernia as a tracer condition.

METHODS

This was a prospective, international, cohort study conducted between Jan 30 and May 21, 2023, in which any hospital performing inguinal hernia repairs was eligible to take part. Consecutive patients of any age undergoing primary inguinal hernia repair were included. A measurement set mapped to the attributes of WHO's Health System Building Blocks was defined to evaluate access (emergency surgery rates, bowel resection rates, and waiting times) and quality (mesh use, day-case rates, and postoperative complications). These were compared across World Bank income groups (high-income, upper-middle-income, lower-middle-income, and low-income countries), adjusted for hospital and country. Factors associated with postoperative complications were explored with a three-level multilevel logistic regression model.

FINDINGS

18 058 patients from 640 hospitals in 83 countries were included, of whom 1287 (7·1%) underwent emergency surgery. Emergency surgery rates increased from high-income to low-income countries (6·8%, 9·7%, 11·4%, 14·2%), accompanied by an increase in bowel resection rates (1·2%, 1·4%, 2·3%, 4·2%). Overall waiting times for elective surgery were similar around the world (median 8·0 months from symptoms to surgery), largely because of delays between symptom onset and diagnosis rather than waiting for treatment. In 14 768 elective operations in adults, mesh use decreased from high-income to low-income countries (97·6%, 94·3%, 80·6%, 61·0%). In patients eligible for day-case surgery (n=12 658), day-case rates were low and variable (50·0%, 38·0%, 42·1%, 44·5%). Complications occurred in 2415 (13·4%) of 18 018 patients and were more common after emergency surgery (adjusted odds ratio 2·06, 95% CI 1·72-2·46) and bowel resection (1·85, 1·31-2·63), and less common after day-case surgery (0·39, 0·34-0·44).

INTERPRETATION

This study demonstrates that elective health care is essential to preventing over-reliance on emergency systems. We identified actionable targets for system strengthening: clear referral pathways and increasing mesh repair in lower-income settings, and boosting day-case surgery in all income settings. These measures might strengthen non-surgical pathways too, reducing the burden on society and health services.

FUNDING

NIHR Global Health Research Unit on Global Surgery and Portuguese Hernia and Abdominal Wall Society (Sociedade Portuguesa de Hernia e Parede Abdominal).

Augmented Reality (AR) in Surgery in Low- and Middle-Income Countries (LMICs): A Scoping Review

Surgical disparities persist in low- and middle-income countries (LMICs). Insufficient access to surgical care places a large burden on these regions, with high mortality rates for otherwise standard procedures performed in high-income countries (HICs). Augmented Reality (AR) and Virtual Reality (VR) now provide us with a platform to improve the delivery of surgical access and training to LMICs. The use of AR technologies to provide additional training to surgeons and residents globally can help bridge the gap and reduce health disparities in LMICs. The goal of this scoping review is to evaluate whether surgical trainees and surgeons from LMICs have access to or use AR software in their training or practice. A systematic search was conducted on seven databases. Inclusion criteria included populations in LMICs with access to AR-based training. Articles using VR software, or those conducted in HICs were excluded from the review. From the 428 records screened, 58 reports were assessed for eligibility, and of these, a total of six studies were included in the review. Five of the six studies used mentors from an HIC, including the United States (US) and the United Kingdom (UK), whereas one study had mentorship from another LMIC. Three surgical specialties were explored: neurosurgery, plastic surgery, and urology. Although the integration of AR in surgical training is promising, the six studies evaluated in this review emphasize that costs and connection issues are major challenges that can set back these technologies in the operating room. Despite these revelations, with certain improvements, AR training programs are promising as they can help to reduce the global disparity in surgical proficiency.

Magnitude of in-hospital mortality and its associated factors among patients undergone laparotomy at tertiary public hospitals, West Oromia, Ethiopia, 2022

INTRODUCTION

Laparotomy surgery, which involves making an incision in the abdominal cavity to treat serious abdominal disease and save the patient's life, causes significant deaths in both developed and developing countries, including Ethiopia. The number studies examining in-hospital mortality rates among individuals that undergone laparotomy surgery and associated risk factors is limited.

OBJECTIVE

To assess the magnitude of in-hospital mortality and its associated factors among patients undergone laparotomy at tertiary hospitals, West Oromia, Ethiopia, 2022.

METHODS

An institutional based retrospective cross-sectional study was conducted from January 1, 2017, to December 31, 2021. Data were collected using systematic random sampling and based on structured and pretested abstraction sheets from 548 medical records and patient register log. Data were checked for completeness and consistency, coded, imported using Epi-data version 4.6, cleaned and analyzed using SPSS version 25 software. Variables with p < 0.2 in the Bi-variable logistic regression analysis were included in the multivariate logistic regression analysis. The fit of the model was checked by the Hosmer‒Lemeshow test. Using the odds ratio adjusted to 95% CI and a p value of 0.05, statistical significance was declared.

RESULTS

A total of 512 patient charts were reviewed, and the response rate was 93.43%. The overall magnitude of in-hospital mortality was 7.42% [95% CI: 5.4-9.8]. American society of Anesthesiology physiological status greater than III [AOR = 7.64 (95% CI: 3.12-18.66)], systolic blood pressure less than 90 mmHg [AOR = 6.11 (95% CI: 1.98-18.80)], preoperative sepsis [AOR = 3.54 (95% CI: 1.53-8.19)], ICU admission [AOR = 4.75 (95% CI: 1.50-14.96)], and total hospital stay greater than 14 days [(AOR = 6.76 (95% CI: 2.50-18.26)] were significantly associated with mortality after laparotomy surgery.

CONCUSSION

In this study, overall in- hospital mortality was high. Early identification patient's American Society of Anesthesiologists physiological status and provision of early appropriate intervention, and pays special attention to patients admitted with low systolic blood pressure, preoperative sepsis, intensive care unit admission and prolonged hospital stay to improve patient outcomes after laparotomy surgery.

Systems issues limiting acute fracture care delivery at a tertiary care hospital in Northern Tanzania

Introduction

sub-Saharan Africa experiences a significant musculoskeletal trauma burden. Among patients who receive surgical treatment, there have been no reports as to how often surgical care is determined to be "adequate" or, if "inadequate", then what hospital and orthopaedic specialty-specific systems limitations might be prohibitive.

Methods

data from patients presenting to the orthopaedic trauma service at a tertiary care center in sub-Saharan Africa were prospectively collected over a 6-week period and then retrospectively reviewed to determine whether the surgical treatment was "adequate" (or otherwise, "inadequate") according to the principle of restoring length, alignment, and rotation. Exclusion criteria included insufficient clinical information; isolated spinal injury; infection; cases involving only removal of hardware; soft-tissue procedures; tumor cases; and medical (non-surgical) conditions.

Results

112 cases were included for analysis. Surgery was indicated in 106 of 112 cases (94.6%), and of those, surgery was performed in 62 cases (58.4%). Among patients who underwent surgery with available post-operative imaging (n=56), surgical treatment was "inadequate" in 24 cases (42.9%). The most common reasons treatment was deemed "inadequate" included unavailability of appropriate implants (n=16), unavailability of intraoperative fluoroscopy (n=10) and incomplete intraoperative evaluation of injury (n=5).

Conclusion

several systems limitations prevent the delivery of adequate surgical treatment in patients with acute orthopaedic traumatic injuries, including lack of intraoperative fluoroscopy and lack of implant availability. This study will serve as a useful baseline for ongoing efforts seeking to improve orthopaedic specialty resource availability and facilitate more effective fracture care in this region.

Gastrointestinal Surgical Outcomes Study (GISOS): a 30-day monocentric prospective cohort study in Ethiopia

OBJECTIVE

The impact of perioperative mortality and morbidity extends globally, playing substantial roles in mortality rates, levels of disability and economic consequences. This study was primarily designed to provide insights into the surgical outcomes of gastrointestinal surgeries carried out in a high-volume centre in Ethiopia in the year 2023.

DESIGN

A 30-day prospective cohort observational study employed.

SETTING

High volume surgical specialised hospital in Ethiopia.

PARTICIPANTS

All adult patients who had abdominal surgery.

OUTCOME MEASURES

30th-day postoperative mortality and complications.

RESULTS

During this prospective observational study, data from 259 patients were collected. This prospective observational study found that 30-day complication rate was 30.5%. Surgical site infection is the leading complications (15.8%) followed by postop acute kidney injury (9.3%). Malignant pathology (adjusted OR (AOR)=1.43 (1.01 to 3.06); p=0.035, ASA III (AOR=4.00 (1.01 to 16.5); p=0.049), ECOG III (AOR=2.8 (1.55 to 7.30); p=0.025) and comorbidity (AOR=2.02 (1.02 to 3.18); p=0.008) had statistically significant association with 30-day complication rates. We also found that a 30-day mortality rate was 14.3%. Emergency surgery (AOR=5.53 (1.4 to 21.6); p=0.014), Eastern Cooperative Oncology Group III (AOR=8.6 (1.01 to 74.1); p=0.0499), American Society of Anesthesiology III (AOR=12.7 (1.9 to 85.5); p=0.009) and comorbidity (AOR=7.5 (1.4 to 39.1); p=0.017) had statistical significance association with a 30-day mortality rate after gastrointestinal surgery.

CONCLUSION

The findings of this study indicated that postoperative mortality and complications were alarmingly high, which highlights the need for innovative solutions to lower postoperative mortality and complications.

Associated factors of mortality and morbidity in emergency and elective abdominal surgery: a two-year prospective cohort study at lacor hospital, Uganda

BACKGROUND

The mortality rate associated with open abdominal surgery is a significant concern for patients and healthcare providers. This is particularly worrisome in Africa due to scarce workforce resources and poor early warning systems for detecting physiological deterioration in patients who develop complications.

METHODS

This prospective cohort study aimed to follow patients who underwent emergency or elective abdominal surgery at Lacor Hospital in Uganda. The participants were patients who underwent abdominal surgery at the hospital between April 27th, 2019 and July 07th, 2021. Trained research staff collected data using standardized forms, which included demographic information (age, gender, telephone contact, and location), surgical indications, surgical procedures, preoperative health status, postoperative morbidity and mortality, and length of hospital stay.

RESULTS

The present study involved 124 patients, mostly male, with an average age of 35 years, who presented with abdominal pain and varying underlying comorbidities. Elective cases constituted 60.2% of the total. The common reasons for emergency and elective surgery were gastroduodenal perforation and cholelithiasis respectively. The complication rate was 17.7%, with surgical site infections being the most frequent. The mortality rate was 7.3%, and several factors such as preoperative hypotension, deranged renal function, postoperative use of vasopressors, and postoperative assisted ventilation were associated with it. Elective and emergency-operated patients showed no significant difference in survival (P-value = 0.41) or length of hospital stay (P-value = 0.17). However, there was a significant difference in morbidity (p < 0.001).

CONCLUSION

Cholelithiasis and gastroduodenal perforation were key surgical indications, with factors like postoperative ventilation and adrenaline infusion linked to mortality. Emergency surgeries had higher complication rates, particularly surgical site infections, despite similar hospital stay and mortality rates compared to elective surgeries.

An international, prospective observational study on traumatic brain injury epidemiology study protocol: GEO-TBI: Incidence

Background

The epidemiology of traumatic brain injury (TBI) is unclear - it is estimated to affect 27-69 million individuals yearly with the bulk of the TBI burden in low-to-middle income countries (LMICs). Research has highlighted significant between-hospital variability in TBI outcomes following emergency surgery, but the overall incidence and epidemiology of TBI remains unclear. To address this need, we established the Global Epidemiology and Outcomes following Traumatic Brain Injury (GEO-TBI) registry, enabling recording of all TBI cases requiring admission irrespective of surgical treatment.

Objective

The GEO-TBI: Incidence study aims to describe TBI epidemiology and outcomes according to development indices, and to highlight best practices to facilitate further comparative research.

Design

Multi-centre, international, registry-based, prospective cohort study.

Subjects

Any unit managing TBI and participating in the GEO-TBI registry will be eligible to join the study. Each unit will select a 90-day study period. All TBI patients meeting the registry inclusion criteria (neurosurgical/ICU admission or neurosurgical operation) during the selected study period will be included in the GEO-TBI: Incidence.

Methods

All units will form a study team, that will gain local approval, identify eligible patients and input data. Data will be collected via the secure registry platform and validated after collection. Identifiers may be collected if required for local utility in accordance with the GEO-TBI protocol.

Data

Data related to initial presentation, interventions and short-term outcomes will be collected in line with the GEO-TBI core dataset, developed following consensus from an iterative survey and feedback process. Patient demographics, injury details, timing and nature of interventions and post-injury care will be collected alongside associated complications. The primary outcome measures for the study will be the Glasgow Outcome at Discharge Scale (GODS) and 14-day mortality. Secondary outcome measures will be mortality and extended Glasgow Outcome Scale (GOSE) at the most recent follow-up timepoint.

COVID-19 and Mortality in the Global Surgical Population: A Systematic Review and Meta-Analysis

INTRODUCTION

To date, no systematic review or meta-analysis has comprehensively estimated the risk of mortality by surgery type on an international scale. We aim to delineate the risk of mortality in patients with COVID-19 who undergo surgery.

METHODS

PubMed (MEDLINE), Scopus, OVID, the World Health Organization Global Literature on Coronavirus Disease, and Corona-Central databases were searched from December 2019 through January 2022. Studies providing data on mortality in patients undergoing surgery were included. The Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines for abstracting data were followed and performed independently by two reviewers. The main outcome was mortality in patients with COVID-19.

RESULTS

Of a total of 4023 studies identified, 46 studies with 80,015 patients met our inclusion criteria. The mean age was 67 y; 57% were male. Surgery types included general (14.9%), orthopedic (23.4%), vascular (6.4%), thoracic (10.6%), and urologic (8.5%). Patients undergoing surgery with COVID-19 elicited a nine-fold increased risk of mortality (relative risk [RR] 8.99, 95% confidence interval [CI] 4.96-16.32) over those without COVID-19. In low-income and middle-income countries (RR: 16.04, 95% CI: 4.59-56.12), the mortality risk was twice as high compared to high-income countries (RR: 7.50, 95% CI: 4.30-13.09).

CONCLUSIONS

Mortality risk in surgical patients with COVID-19 compared to those without is increased almost 10-fold. The risk was highest in low-income and middle-income countries compared to high-income countries, suggesting a disproportionate effect of the pandemic on resource-constrained regions.

Artificial intelligence in surgery

Artificial intelligence (AI) is rapidly emerging in healthcare, yet applications in surgery remain relatively nascent. Here we review the integration of AI in the field of surgery, centering our discussion on multifaceted improvements in surgical care in the preoperative, intraoperative and postoperative space. The emergence of foundation model architectures, wearable technologies and improving surgical data infrastructures is enabling rapid advances in AI interventions and utility. We discuss how maturing AI methods hold the potential to improve patient outcomes, facilitate surgical education and optimize surgical care. We review the current applications of deep learning approaches and outline a vision for future advances through multimodal foundation models.

A prospective study to evaluate the contribution of the pediatric appendicitis score in the decision process

BACKGROUND

The objective of this study was to assess the likelihood of acute appendicitis (AA) in children presenting with abdominal symptoms at the emergency department (ED), based on their prior primary care (PC) consultation history.

METHODS

Between February and June 2021, we prospectively enrolled all children presenting at the ED with acute abdominal pain indicative of possible acute appendicitis (AA). Subsequently, they were categorized into three groups: those assessed by a PC physician (PG), those brought in by their family without a prior consultation (FG), and those admitted after a PC consultation without being assessed as such. The primary objective was to assess the probability of AA diagnosis using the Pediatric Appendicitis Score (PAS). Secondary objectives included analyzing PAS and C-reactive protein (CRP) levels based on the duration of pain and final diagnoses.

RESULTS

124 children were enrolled in the study (PG, n = 56; FG, n = 55; NG, n = 13). Among them, 29 patients (23.4%) were diagnosed with AA, with 13 cases (23.2%) from the PG and 14 cases (25.4%) from the FG. The mean PAS scores for AA cases from the PG and FG were 6.69 ± 1.75 and 7.57 ± 1.6, respectively, (p = 0.3340). Both PAS scores and CRP levels showed a significant correlation with AA severity. No cases of AA were observed with PAS scores < 4.

CONCLUSIONS

There was no significant difference in PAS scores between patients addressed by PG and FG, even though PAS scores tended to be higher for patients with AA. We propose a new decision-making algorithm for PC practice, which incorporates inflammatory markers and pain duration.

TRIAL REGISTRATION

Institutional Ethics Committee registration number: 447-2021-103 (10/01/2021).

CLINICAL TRIALS REGISTRATION NUMBER

ClinicalTrials.gov Identifier: NCT04885335 (Registered on 13/05/2021).

Consensus-Based Development of a Global Registry for Traumatic Brain Injury: Establishment, Protocol, and Implementation

BACKGROUND AND OBJECTIVES

Global disparity exists in the demographics, pathology, management, and outcomes of surgically treated traumatic brain injury (TBI). However, the factors underlying these differences, including intervention effectiveness, remain unclear. Establishing a more accurate global picture of the burden of TBI represents a challenging task requiring systematic and ongoing data collection of patients with TBI across all management modalities. The objective of this study was to establish a global registry that would enable local service benchmarking against a global standard, identification of unmet need in TBI management, and its evidence-based prioritization in policymaking.

METHODS

The registry was developed in an iterative consensus-based manner by a panel of neurotrauma professionals. Proposed registry objectives, structure, and data points were established in 2 international multidisciplinary neurotrauma meetings, after which a survey consisting of the same data points was circulated within the global neurotrauma community. The survey results were disseminated in a final meeting to reach a consensus on the most pertinent registry variables.

RESULTS

A total of 156 professionals from 53 countries, including both high-income countries and low- and middle-income countries, responded to the survey. The final consensus-based registry includes patients with TBI who required neurosurgical admission, a neurosurgical procedure, or a critical care admission. The data set comprised clinically pertinent information on demographics, injury characteristics, imaging, treatments, and short-term outcomes. Based on the consensus, the Global Epidemiology and Outcomes following Traumatic Brain Injury (GEO-TBI) registry was established.

CONCLUSION

The GEO-TBI registry will enable high-quality data collection, clinical auditing, and research activity, and it is supported by the World Federation of Neurosurgical Societies and the National Institute of Health Research Global Health Program. The GEO-TBI registry ( https://geotbi.org ) is now open for participant site recruitment. Any center involved in TBI management is welcome to join the collaboration to access the registry.

Postoperative outcomes of pediatric patients with perioperative COVID-19 infection: a systematic review and meta-analysis of observational studies

OBJECTIVE

To quantify the risk of adverse postoperative outcomes in pediatric patients with COVID-19 infection.

METHODS

We searched PubMed, Embase, Cochrane Library from December 2019 to 21 April 2023. Observational cohort studies that reported postoperative early mortality and pulmonary complications of pediatric patients with confirmed COVID-19-positive compared with COVID-19-negative were eligible for inclusion. We excluded pediatric patients underwent organ transplantation or cardiac surgery. Reviews, case reports, letters, and editorials were also excluded. We used the Newcastle-Ottawa Scale to assess the methodological quality and risk of bias for each included study. The primary outcome was postoperative early mortality, defined as mortality within 30 days after surgery or during hospitalization. The random-effects model was performed to assess the pooled estimates, which were expressed as risk ratio (RR) or mean difference (MD) with 95% confidence intervals (CI).

RESULTS

9 studies involving 23,031 pediatric patients were included, and all studies were rated as high quality. Compared with pediatric patients without COVID-19, pediatric patients with COVID-19 showed a significantly increased risk of postoperative pulmonary complications (PPCs) (RR = 4.24; 95% CI 2.08-8.64). No clear evidence was found for differences in postoperative early mortality (RR = 0.84; 95% CI 0.34-2.06), postoperative intensive care unit (ICU) admission (RR = 0.80; 95% CI 0.39-1.68), and length of hospital stay (MD = 0.35, 95% CI -1.81-2.51) between pediatric patients with and without COVID-19.

CONCLUSION

Perioperative COVID-19 infection was strongly associated with increased risk of PPCs, but it did not increase the risk of postoperative early mortality, the rate of postoperative ICU admission, and the length of hospital stay in pediatric patients. Our preplanned sensitivity analyses confirmed the robustness of our study findings.

Pancreatic surgery outcomes: multicentre prospective snapshot study in 67 countries

BACKGROUND

Pancreatic surgery remains associated with high morbidity rates. Although postoperative mortality appears to have improved with specialization, the outcomes reported in the literature reflect the activity of highly specialized centres. The aim of this study was to evaluate the outcomes following pancreatic surgery worldwide.

METHODS

This was an international, prospective, multicentre, cross-sectional snapshot study of consecutive patients undergoing pancreatic operations worldwide in a 3-month interval in 2021. The primary outcome was postoperative mortality within 90 days of surgery. Multivariable logistic regression was used to explore relationships with Human Development Index (HDI) and other parameters.

RESULTS

A total of 4223 patients from 67 countries were analysed. A complication of any severity was detected in 68.7 per cent of patients (2901 of 4223). Major complication rates (Clavien-Dindo grade at least IIIa) were 24, 18, and 27 per cent, and mortality rates were 10, 5, and 5 per cent in low-to-middle-, high-, and very high-HDI countries respectively. The 90-day postoperative mortality rate was 5.4 per cent (229 of 4223) overall, but was significantly higher in the low-to-middle-HDI group (adjusted OR 2.88, 95 per cent c.i. 1.80 to 4.48). The overall failure-to-rescue rate was 21 per cent; however, it was 41 per cent in low-to-middle- compared with 19 per cent in very high-HDI countries.

CONCLUSION

Excess mortality in low-to-middle-HDI countries could be attributable to failure to rescue of patients from severe complications. The authors call for a collaborative response from international and regional associations of pancreatic surgeons to address management related to death from postoperative complications to tackle the global disparities in the outcomes of pancreatic surgery (NCT04652271; ISRCTN95140761).

Inequities in global cancer surgery: Challenges and solutions

The disparity in access to and quality of surgical cancer care between high and low resource settings impacts immediate and long-term oncological outcomes. With cancer incidence and mortality set to increase rapidly in the next few decades, we examine the factors leading to inequities in global cancer surgery, and look at potential solutions to overcome these challenges.

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

BACKGROUND

The outcomes of liver surgery worldwide remain unknown. The true population-based outcomes are likely different to those vastly reported that reflect the activity of highly specialized academic centers. The aim of this study was to measure the true worldwide practice of liver surgery and associated outcomes by recruiting from centers across the globe. The geographic distribution of liver surgery activity and complexity was also evaluated to further understand variations in outcomes.

METHODS

LiverGroup.org was an international, prospective, multicenter, cross-sectional study following the Global Surgery Collaborative Snapshot Research approach with a 3-month prospective, consecutive patient enrollment within January-December 2019. Each patient was followed up for 90 days postoperatively. All patients undergoing liver surgery at their respective centers were eligible for study inclusion. Basic demographics, patient and operation characteristics were collected. Morbidity was recorded according to the Clavien-Dindo Classification of Surgical Complications. Country-based and hospital-based data were collected, including the Human Development Index (HDI). (NCT03768141).

RESULTS

A total of 2159 patients were included from six continents. Surgery was performed for cancer in 1785 (83%) patients. Of all patients, 912 (42%) experienced a postoperative complication of any severity, while the major complication rate was 16% (341/2159). The overall 90-day mortality rate after liver surgery was 3.8% (82/2,159). The overall failure to rescue rate was 11% (82/ 722) ranging from 5 to 35% among the higher and lower HDI groups, respectively.

CONCLUSIONS

This is the first to our knowledge global surgery study specifically designed and conducted for specialized liver surgery. The authors identified failure to rescue as a significant potentially modifiable factor for mortality after liver surgery, mostly related to lower Human Development Index countries. Members of the LiverGroup.org network could now work together to develop quality improvement collaboratives.

Barriers to Surgical Outcomes Research in Low- and Middle-Income Countries: A Scoping Review

INTRODUCTION

Systematic collection and analysis of surgical outcomes data is a cornerstone of surgical quality improvement. Unfortunately, there remains a dearth of surgical outcomes data from low- and middle-income countries (LMICs). To improve surgical outcomes in LMICs, it is essential to have the ability to collect, analyze, and report risk-adjusted postoperative morbidity and mortality data. This study aimed to review the barriers and challenges to developing perioperative registries in LMIC settings.

METHODS

We conducted a scoping review of all published literature on barriers to conducting surgical outcomes research in LMICs using PubMed, Embase, Scopus, and GoogleScholar. Keywords included 'surgery', 'outcomes research', 'registries', 'barriers', and synonymous Medical Subject Headings derivatives. Articles found were subsequently reference-mined. All relevant original research and reviews published between 2000 and 2021 were included. The performance of routine information system management framework was used to organize identified barriers into technical, organizational, or behavioral factors.

RESULTS

Twelve articles were identified in our search. Ten articles focused specifically on the creation, success, and obstacles faced during the implementation of trauma registries. Technical factors reported by 50% of the articles included limited access to a digital platform for data entry, lack of standardization of forms, and complexity of said forms. 91.7% articles mentioned organizational factors, including the availability of resources, financial constraints, human resources, and lack of consistent electricity. Behavioral factors highlighted by 66.6% of the studies included lack of team commitment, job constraints, and clinical burden, which contributed to poor compliance and dwindling data collection over time.

CONCLUSIONS

There is a paucity of published literature on barriers to developing and maintaining perioperative registries in LMICs. There is an immediate need to study and understand barriers and facilitators to the continuous collection of surgical outcomes in LMICs.

Failure to Rescue and Mortality Differences After Appendectomy in a Low-Middle-Income Country and the United States

BACKGROUND

Major disparities in complications and mortality after appendectomy between countries with different income levels have not been well characterized, as comparative studies at patient level between countries are scant. This study aimed to investigate variations in postoperative complications, mortality, and failure to rescue after appendectomy between a high-income country and a low-to-middle-income country.

METHODS

Hospital discharges on adult patients who underwent appendectomy were extracted from administrative databases from Colombia and 2 states of the United States (Florida and New York). Outcomes included major postoperative complications, in-hospital mortality, and failure to rescue. Univariate analyses were conducted to compare outcomes between the 2 countries. Multivariable logistic regression analyses were conducted to examine the independent effect of country on outcomes after adjustment for patient age, sex, comorbidity index, severity of appendicitis, and appendectomy route (laparoscopic/open).

RESULTS

A total of 62,338 cases from Colombia and 57,987 from the United States were included in the analysis. Patients in Colombia were significantly younger and healthier but had a higher incidence of peritonitis. Use of laparoscopy was significantly lower in Colombia (5.9% vs 89.4%; P < .0001). After adjustment for covariates, multivariable logistic regression analyses revealed that compared to the United States, Colombia had lower complication rates (2.8% vs 6.6%; odds ratio [OR], 0.41; 95% confidence interval [CI], 0.39-0.44; P < .0001) but higher mortality (0.44% vs 0.08%; OR, 8.92; 95% CI, 5.69-13.98; P < .0001) and failure to rescue (13.6% vs 1.0%; OR, 17.01; 95% CI, 10.66-27.16; P < .0001).

CONCLUSIONS

Despite lower rates of postoperative complications, in-hospital mortality after appendectomy was higher in Colombia than in the United States. This difference may be explained by higher rates of failure to rescue in the low-to-middle-income country (ie, decreased ability of Colombian hospitals to rescue patients from complications).

Evaluating the status of the Lancet Commission on Global Surgery indicators for India

For universal surgical, obstetric, trauma, and anesthesia care by 2030, the Lancet Commission on Global Surgery (LCoGS) suggested tracking six indicators. We reviewed academic and policy literature to investigate the current state of LCoGS indicators in India. There was limited primary data for access to timely essential surgery, risk of impoverishing and catastrophic health expenditures due to surgery, though some modeled estimates are present. Surgical specialist workforce estimates are heterogeneous across different levels of care, urban and rural areas, and diverse health sectors. Surgical volumes differ widely across demographic, socio-economic, and geographic cohorts. Perioperative mortality rates vary across procedures, diagnoses, and follow-up time periods. Available data suggest India falls short of achieving global targets. This review highlights the evidence gap for India's surgical care planning. India needs a systematic subnational mapping of indicators and adaptation of targets as per the country's health needs for equitable and sustainable planning.

Predictors of mortality for perforated peptic ulcer disease in Malawi

BACKGROUND

Mortality from perforated peptic ulcer disease (PUD) remains high, especially in sub-Saharan Africa. We sought to identify predictors of mortality following surgery for perforated PUD.

METHODS

We performed a retrospective study of acute care surgeries at Kamuzu Central Hospital (KCH) in Malawi from 2013 to 2022. Patients undergoing omental patch surgeries were included. Bivariate and multivariate analyses were used to model predictors of mortality.

RESULTS

A total of 248 patients were included. The mean age was 30 ± 15 years. Ninety percent were male. Mortality rate was 22.2%. Predictors of mortality included age (adjusted odds ratio [AOR] 1.06, 95% confidence interval [CI] 1.03-1.09), shock index (AOR 1.86, 95% CI 1.14-3.03), days to operative intervention (AOR 1.44, 95% CI 1.10-1.88), and presence of complications (AOR 9.65, 95% CI 3.79-24.6).

CONCLUSIONS

Mortality following surgery for perforated PUD remains high in this low-resource environment. In-hospital delay is a significant and modifiable predictor of mortality.

Incidence and predictors of perioperative mortality in a low-resource country, Ethiopia: a prospective follow-up study

OBJECTIVE

This study aimed to assess the incidence and identify predictors of perioperative mortality among the adult age group at Tibebe Ghion Specialised Hospital.

DESIGN

A single-centre prospective follow-up study.

SETTING

A tertiary hospital in North West Ethiopia.

PARTICIPANTS

We enrolled 2530 participants who underwent surgery in the current study. All adults aged 18 and above were included except those with no telephone.

PRIMARY OUTCOME MEASURES

The primary outcome was time to death measured in days from immediate postoperative time up to the 28th day following surgery.

RESULT

A total of 2530 surgical cases were followed for 67 145 person-days. There were 92 deaths, with an incidence rate of 1.37 (95% CI 1.11 to 1.68) deaths per 1000 person-day observations. Regional anaesthesia was significantly associated with lower postoperative mortality (adjusted hazard ratio (AHR) 0.18, 95% CI 0.05 to 0.62). Patients aged ≥65 years (AHR 3.04, 95% CI 1.65 to 5.75), American Society of Anesthesiologist (ASA) physical status III (AHR 2.41, 95% CI 1.1.13 to 5.16) and IV (AHR 2.74, 95% CI 1.08 to 6.92), emergency surgery (AHR 1.85, 95% CI 1.02 to 3.36) and preoperative oxygen saturation <95% (AHR 3.14, 95% CI 1.85 to 5.33) were significantly associated with a higher risk of postoperative mortality.

CONCLUSION

The postoperative mortality rate at Tibebe Ghion Specialised Hospital was high. Age ≥65, ASA physical status III and IV, emergency surgery, and preoperative oxygen saturation <95% were significant predictors of postoperative mortality. Patients with the identified predictors should be offered targeted treatment.

Strategies to minimise and monitor biases and imbalances by arm in surgical cluster randomised trials: evidence from ChEETAh, a trial in seven low- and middle-income countries

BACKGROUND

Cluster randomised controlled trials (cRCT) present challenges regarding risks of bias and chance imbalances by arm. This paper reports strategies to minimise and monitor biases and imbalances in the ChEETAh cRCT.

METHODS

ChEETAh was an international cRCT (hospitals as clusters) evaluating whether changing sterile gloves and instruments prior to abdominal wound closure reduces surgical site infection at 30 days postoperative. ChEETAh planned to recruit 12,800 consecutive patients from 64 hospitals in seven low-middle income countries. Eight strategies to minimise and monitor bias were pre-specified: (1) minimum of 4 hospitals per country; (2) pre-randomisation identification of units of exposure (operating theatres, lists, teams or sessions) within clusters; (3) minimisation of randomisation by country and hospital type; (4) site training delivered after randomisation; (5) dedicated 'warm-up week' to train teams; (6) trial specific sticker and patient register to monitor consecutive patient identification; (7) monitoring characteristics of patients and units of exposure; and (8) low-burden outcome-assessment.

RESULTS

This analysis includes 10,686 patients from 70 clusters. The results aligned to the eight strategies were (1) 6 out of 7 countries included ≥ 4 hospitals; (2) 87.1% (61/70) of hospitals maintained their planned operating theatres (82% [27/33] and 92% [34/37] in the intervention and control arms); (3) minimisation maintained balance of key factors in both arms; (4) post-randomisation training was conducted for all hospitals; (5) the 'warm-up week' was conducted at all sites, and feedback used to refine processes; (6) the sticker and trial register were maintained, with an overall inclusion of 98.1% (10,686/10,894) of eligible patients; (7) monitoring allowed swift identification of problems in patient inclusion and key patient characteristics were reported: malignancy (20.3% intervention vs 12.6% control), midline incisions (68.4% vs 58.9%) and elective surgery (52.4% vs 42.6%); and (8) 0.4% (41/9187) of patients refused consent for outcome assessment.

CONCLUSION

cRCTs in surgery have several potential sources of bias that include varying units of exposure and the need for consecutive inclusion of all eligible patients across complex settings. We report a system that monitored and minimised the risks of bias and imbalances by arm, with important lessons for future cRCTs within hospitals.

Is perioperative COVID-19 really associated with worse surgical outcomes? A nationwide COVIDSurg propensity-matched analysis

BACKGROUND

Patients undergoing surgery with perioperative COVID-19 are suggested to have worse outcomes, but whether this is COVID-related or due to selection bias remains unclear. We aimed to compare the postoperative outcomes of patients with and without perioperative COVID-19.

METHODS

Patients with perioperative COVID-19 diagnosed within 7 days before or 30 days after surgery between February and July 2020 from 68 US hospitals in COVIDSurg, an international multicenter database, were 1:1 propensity score matched to patients without COVID-19 undergoing similar procedures in the 2012 American College of Surgeons National Surgical Quality Improvement Program database. The matching criteria included demographics (e.g., age, sex), comorbidities (e.g., diabetes, chronic obstructive pulmonary disease, chronic kidney disease), and operation characteristics (e.g., type, urgency, complexity). The primary outcome was 30-day hospital mortality. Secondary outcomes included hospital length of stay and 13 postoperative complications (e.g., pneumonia, renal failure, surgical site infection).

RESULTS

A total of 97,936 patients were included, 1,054 with and 96,882 without COVID-19. Prematching, COVID-19 patients more often underwent emergency surgery (76.1% vs. 10.3%, p < 0.001). A total of 843 COVID-19 and 843 non-COVID-19 patients were successfully matched based on demographics, comorbidities, and operative characteristics. Postmatching, COVID-19 patients had a higher mortality (12.0% vs. 8.1%, p = 0.007), longer length of stay (6 [2-15] vs. 5 [1-12] days), and higher rates of acute renal failure (19.3% vs. 3.0%, p < 0.001), sepsis (13.5% vs. 9.0%, p = 0.003), and septic shock (11.8% vs. 6.0%, p < 0.001). They also had higher rates of thromboembolic complications such as deep vein thrombosis (4.4% vs. 1.5%, p < 0.001) and pulmonary embolism (2.5% vs. 0.4%, p < 0.001) but lower rates of bleeding (11.6% vs. 26.1%, p < 0.001).

CONCLUSION

Patients undergoing surgery with perioperative COVID-19 have higher rates of 30-day mortality and postoperative complications, especially thromboembolic, compared with similar patients without COVID-19 undergoing similar surgeries. Such information is crucial for the complex surgical decision making and counseling of these patients.

LEVEL OF EVIDENCE

Prognostic and Epidemiologic; Level IV.

Spectrum, Management, and Outcomes of Abdominal Surgical Emergencies at a Referral Hospital in North West Cameroon

Purpose: Abdominal surgical emergencies are a major health burden in low- and middle-income countries where management is often very challenging, and associated with high morbidity and mortality. The spectrum, management, and outcomes of abdominal surgical emergencies needs to be updated.Methods: This was a hospital-based retrospective cross-sectional study carried out in Bamenda, Cameroon over a 2-year period. Records of patients who met the inclusion criteria were reviewed, with pre-, intra- and postoperative data collected and analyzed.Results: There were 207 patients included in this retrospective review (male to female ratio of 1.4:1. The mean age was 47.4 (± 19.4) years. Intestinal obstruction (34.8%) and perforated peptic ulcers (15.5%) were the most common abdominal surgical emergencies. The median delay and interquartile range to presentation and in-hospital delay were 6 (4) days and 8 (12) hours, respectively. The mean length of hospital stay post-surgery was 11days. There were 48.3% of patients who developed a complication; 34.78% were major, 17.9% had an unplanned reoperation, and 15 (7.2%) were readmitted after discharge. The 30-day in hospital mortality was 19.8%. Mortality was independently associated with a high American Society of Anesthesiologists (ASA) score; ASA score > 3, age > 60 years, and referral from other health facilities.Conclusion: Intestinal obstructions from intraperitoneal neoplasm is the most common cause of abdominal surgical emergency in North West Cameroon. Abdominal emergencies here are associated with a very high morbidity and mortality in males > 60 years with an ASA score > 3 and with more than one comorbidity.

Pediatric Surgical Waitlist in Low Middle Income Countries during the COVID-19 Pandemic

Purpose

COVID-19 led to significant reduction in surgery worldwide. Studies, however, of the effect on surgical volume for pediatric patients in low- and middle-income countries (LMICs) are limited.

Methods

A survey was developed to estimate waitlists in LMICs for priority surgical conditions in children. The survey was piloted and revised before it was deployed over email to 19 surgeons. Pediatric surgeons at 15 different sites in 8 countries in Sub-Saharan Africa and Ecuador completed the survey from February 2021 to June 2021. The survey included the total number of children awaiting surgery and estimates for specific conditions. Respondents were also able to add additional procedures.

Results

Public hospitals had longer wait times than private facilities. The median waitlist was 90 patients and the median wait time was 2 months for elective surgeries.

Conclusion

Lengthy surgical wait times affect surgical access in LMICs. COVID-19 had been associated with surgical delays around the world, exacerbating existing surgical backlogs. Our results revealed significant delays for elective, urgent and emergent cases across Sub-Saharan Africa. Stakeholders should consider approaches to scale the limited surgical and perioperative resources in LMICs, create mitigation strategies for future pandemics, and establish ways to monitor waitlists on an ongoing basis.

Delayed Presentation and Referral Time from General Practitioners Contribute to Increased Complicated Appendicitis during the Initial COVID-19 Pandemic Period in Japan

Objectives

This study aims to investigate the impact of the coronavirus disease 2019 (COVID-19) pandemic on the situation of acute appendicitis (AA) with respect to patients' and general practitioners' behaviors in a general community hospital in Japan.

Methods

The surgical outcomes and periods from symptom onset to medical presentation besides practitioners' referral time for consecutive AA patients were compared between the control (January 2016 to March 2020) and COVID-19 periods (April 2020 to April 2021).

Results

Eighty-three patients who underwent emergency surgery for AA were reviewed. Complicated appendicitis significantly increased in the COVID-19 period (63.6% vs. 31.2%, P = 0.023). In the COVID-19 period, the time from symptom onset to the medical presentation (2.2 vs. 0.9 days, P < 0.001) was significantly longer than in the control period. Among the patients who first presented to a general practitioner, the referral time from the practitioner to our hospital was significantly longer in the COVID-19 period (1.6 vs. 0.7 days, P = 0.017). Furthermore, among patients with a fever of higher than 38°C at medical presentation, the time from symptom onset to medical presentation was significantly longer in the COVID-19 period (3.0 vs. 0.7 days, P = 0.015). There was no difference in severe postoperative complications.

Conclusions

Hesitation to seek surgical treatment for AA was seen in both the patients and practitioners in the COVID-19 period. The delay in surgical treatment presumably led to the increase in severe AA. In a pandemic era, timely care for emergent conditions is a crucial challenge.

The Hellenic Emergency Laparotomy Study (HELAS): A Prospective Multicentre Study on the Outcomes of Emergency Laparotomy in Greece

BACKGROUND

Emergency laparotomy (EL) is accompanied by high post-operative morbidity and mortality which varies significantly between countries and populations. The aim of this study is to report outcomes of emergency laparotomy in Greece and to compare them with the results of the National Emergency Laparotomy Audit (NELA).

METHODS

This is a multicentre prospective cohort study undertaken between 01.2019 and 05.2020 including consecutive patients subjected to EL in 11 Greek hospitals. EL was defined according to NELA criteria. Demographics, clinical variables, and post-operative outcomes were prospectively registered in an online database. Multivariable logistic regression analysis was used to identify independent predictors of post-operative mortality.

RESULTS

There were 633 patients, 53.9% males, ASA class III/IV 43.6%, older than 65 years 58.6%. The most common operations were small bowel resection (20.5%), peptic ulcer repair (12.0%), adhesiolysis (11.8%) and Hartmann's procedure (11.5%). 30-day post-operative mortality reached 16.3% and serious complications occurred in 10.9%. Factors associated with post-operative mortality were increasing age and ASA class, dependent functional status, ascites, severe sepsis, septic shock, and diabetes. HELAS cohort showed similarities with NELA patients in terms of demographics and preoperative risk. Post-operative utilisation of ICU was significantly lower in the Greek cohort (25.8% vs 56.8%) whereas 30-day post-operative mortality was significantly higher (16.3% vs 8.7%).

CONCLUSION

In this study, Greek patients experienced markedly worse mortality after emergency laparotomy compared with their British counterparts. This can be at least partly explained by underutilisation of critical care by surgical patients who are at high risk for death.

Pathways to effective surgical coverage in a lower-middle-income country: A multiple methods study of the family physician-led generalist surgical team in rural Nepal

The Lancet Commission on Global Surgery (LCoGS) recommends using specialist surgical workforce density as one of 6 core indicators for monitoring universal access to safe, affordable surgical and anaesthesia care. Using Nepal as a case study, we explored the capacity of a generalist workforce (led by a family physician or MD general practitioner and non-physician anaesthetist) to enable effective surgical delivery through task-shifting. Using a multiple-methods approach, we retrospectively mapped essential surgical care and the enabling environment for surgery in 39 hospitals in 25 remote districts in Nepal and compared it with LCoGS indicators. All 25 districts performed surgery, 21 performed Caesarean section (CS), and 5 met at least 50% of district CS needs. Generalist surgical teams performed CS, the essential major operation at the district level, and very few laparotomies, but no operative orthopaedics. The density of specialist Surgeon/Anaesthesiologist/Obstetrician (SAO) was 0·4/100,000; that of Generalist teams (gSAO) led by a family physician (MD General Practitioners-MDGP) supported by non-physician anaesthetists was eight times higher at 3·1/100,000. gSAO presence was positively associated with a two-fold increase in CS availability. All surgical rates were well below LCoGS targets. 46% of hospitals had adequate enabling environments for surgery, 28% had functioning anaesthesia machines, and 75% had blood transfusion services. Despite very low SAO density, and often inadequate enabling environment, surgery can be done in remote districts. gSAO teams led by family physicians are providing essential surgery, with CS the commonest major operation. gSAO density is eight times higher than specialists and they can undertake more complex operations than just CS alone. These family physician-led functional teams are providing a pathway to effective surgical coverage in remote Nepal.

Impact of the COVID-19 pandemic on the management and outcomes of emergency surgical patients: A retrospective cohort study

INTRODUCTION

The COVID-19 pandemic has led to drastic measures being implemented for the management of surgical patients across all health services worldwide, including the National Health Service in the United Kingdom. It is suspected that the virus has had a detrimental effect on perioperative morbidity and mortality. Therefore, the aim of this study was to assess the impact of the COVID-19 pandemic on these outcomes in emergency general surgical patients.

METHODS

Emergency general surgical admissions were included in this retrospective cohort study in one of the COVID-19 hotspots in the South East of England. The primary outcome was the 30-day mortality rate. Secondary outcomes included the length of stay in hospital, complication rate and severity grade and admission rates to the ITU.

RESULTS

Of 123 patients, COVID-19 was detected in 12.2%. Testing was not carried out in 26%. When comparing COVID-positive to COVID-negative patients, the mean age was 71.8 + 8.8 vs. 50.7 + 5.7, respectively, and female patients accounted for 40.0 vs. 52.6%. The 30-day mortality rate was 26.7 vs. 3.9 (OR 6.49, p = 0.02), respectively. The length of stay in hospital was 20.5 + 22.2 vs. 7.7 + 9.8 (p < 0.01), the rate of complications was 80.0 vs. 23.7 (OR 12.9, p < 0.01), and the rate of admission to the ITU was 33.3 vs. 7.9% (OR 5.83, p = 0.01).

CONCLUSION

This study demonstrates the detrimental effect of COVID-19 on emergency general surgery, with significantly worsened surgical outcomes.

Sex-Based Differences in Survival Among Patients with Acute Abdomen Undergoing Surgery in Malawi: A Propensity Weighted Analysis

INTRODUCTION

Sex disparities in access to health care in low-resource settings have been demonstrated. Still, there has been little research on the effect of sex on postoperative outcomes. We evaluated the relationship between sex and mortality after emergency abdominal surgery.

METHODS

We performed a retrospective cohort study using the acute care surgery database at Kamuzu Central Hospital (KCH) in Malawi. We included patients who underwent emergency abdominal surgery between 2013 and 2021. We created a propensity score weighted Cox proportional hazards model to assess the relationship between sex and inpatient survival.

RESULTS

We included 2052 patients in the study, and 76% were males. The most common admission diagnosis in both groups was bowel obstruction. Females had a higher admission shock index than males (0.91 vs. 0.81, p < 0.001) and a longer delay from admission until surgery (1.47 vs. 0.79 days, p < 0.001). Females and males had similar crude postoperative mortality (16.3% vs. 15.3%, p = 0.621). The final Cox proportional hazards regression model was based on the propensity-weighted cohort. The mortality hazard ratio was 0.65 among females compared to males (95% CI 0.46-0.92, p = 0.014).

CONCLUSIONS

Our results show a survival advantage among female patients undergoing emergency abdominal surgery despite sex-based disparities in access to surgical care that favors males. Further research is needed to understand the mechanisms underlying these findings.

Surgical Apgar score as a predictor of outcomes in patients following laparotomy at Mulago National Referral Hospital, Uganda: a prospective cohort study

BACKGROUND

Postoperative complications and mortality following laparotomy have remained high worldwide. Early postoperative risk stratification is essential to improve outcomes and clinical care. The surgical Apgar score (SAS) is a simple and objective bedside prediction tool that can guide a surgeon's postoperative decision making. The objective of this study was to evaluate the performance of SAS in predicting outcomes in patients undergoing laparotomy at Mulago hospital.

METHOD

A prospective observational study was conducted among eligible adult patients undergoing laparotomy at Mulago hospital and followed up for 4 months. We collected data on the patient's preoperative and intraoperative characteristics. Using the data generated, SAS was calculated, and patients were classified into 3 groups namely: low (8-10), medium (5-7), and high (0-4). Primary outcomes were in-hospital major complications and mortality. Data was presented as proportions or mean (standard deviation) or median (interquartile range) as appropriate. We used inferential statistics to determine the association between the SAS and the primary outcomes while the SAS discriminatory ability was determined from the receiver-operating curve (ROC) analysis.

RESULTS

Of the 151 participants recruited, 103 (68.2%) were male and the mean age was 40.6 ± 15. Overall postoperative in-hospital major complications and mortality rates were 24.2% and 10.6%, respectively. The participants with a high SAS category had an18.4 times risk (95% CI, 1.9-177, p = 0.012) of developing major complications, while those in medium SAS category had 3.9 times risk (95% CI, 1.01-15.26, p = 0.048) of dying. SAS had a fair discriminatory ability for in-hospital major complications and mortality with the area under the curve of 0.75 and 0.77, respectively. The sensitivity and specificity of SAS ≤ 6 for major complications were 60.5% and 81.14% respectively, and for death 54.8% and 81.3%, respectively.

CONCLUSION

SAS of ≤ 6 is associated with an increased risk of major complications and/or mortality. SAS has a high specificity with an overall fair discriminatory ability of predicting the risk of developing in-hospital major complications and/or death following laparotomy.