Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

BACKGROUND

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

METHODS

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

FINDINGS

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

INTERPRETATION

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

FUNDING

National Institute for Health Research Global Health Research Unit.

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

BACKGROUND

Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide.

METHODS

A multimethods analysis was performed as part of the GlobalSurg 3 study-a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital.

FINDINGS

Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3·85 [95% CI 2·58-5·75]; p<0·0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63·0% vs 82·7%; OR 0·35 [0·23-0·53]; p<0·0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer.

INTERPRETATION

Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised.

FUNDING

National Institute for Health and Care Research.

Dynamics of disease characteristics and clinical management of critically ill COVID-19 patients over the time course of the pandemic: an analysis of the prospective, international, multicentre RISC-19-ICU registry

Background

It remains elusive how the characteristics, the course of disease, the clinical management and the outcomes of critically ill COVID-19 patients admitted to intensive care units (ICU) worldwide have changed over the course of the pandemic.

Methods

Prospective, observational registry constituted by 90 ICUs across 22 countries worldwide including patients with a laboratory-confirmed, critical presentation of COVID-19 requiring advanced organ support. Hierarchical, generalized linear mixed-effect models accounting for hospital and country variability were employed to analyse the continuous evolution of the studied variables over the pandemic.

Results

Four thousand forty-one patients were included from March 2020 to September 2021. Over this period, the age of the admitted patients (62 [95% CI 60–63] years vs 64 [62–66] years, p < 0.001) and the severity of organ dysfunction at ICU admission decreased (Sequential Organ Failure Assessment 8.2 [7.6–9.0] vs 5.8 [5.3–6.4], p < 0.001) and increased, while more female patients (26 [23–29]% vs 41 [35–48]%, p < 0.001) were admitted. The time span between symptom onset and hospitalization as well as ICU admission became longer later in the pandemic (6.7 [6.2–7.2| days vs 9.7 [8.9–10.5] days, p < 0.001). The PaO₂/FiO₂ at admission was lower (132 [123–141] mmHg vs 101 [91–113] mmHg, p < 0.001) but showed faster improvements over the initial 5 days of ICU stay in late 2021 compared to early 2020 (34 [20–48] mmHg vs 70 [41–100] mmHg, p = 0.05). The number of patients treated with steroids and tocilizumab increased, while the use of therapeutic anticoagulation presented an inverse U-shaped behaviour over the course of the pandemic. The proportion of patients treated with high-flow oxygen (5 [4–7]% vs 20 [14–29], p < 0.001) and non-invasive mechanical ventilation (14 [11–18]% vs 24 [17–33]%, p < 0.001) throughout the pandemic increased concomitant to a decrease in invasive mechanical ventilation (82 [76–86]% vs 74 [64–82]%, p < 0.001). The ICU mortality (23 [19–26]% vs 17 [12–25]%, p < 0.001) and length of stay (14 [13–16] days vs 11 [10–13] days, p < 0.001) decreased over 19 months of the pandemic.

Conclusion

Characteristics and disease course of critically ill COVID-19 patients have continuously evolved, concomitant to the clinical management, throughout the pandemic leading to a younger, less severely ill ICU population with distinctly different clinical, pulmonary and inflammatory presentations than at the onset of the pandemic.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-022-04065-2.

Primary Tuberculous Mastitis: The first report from Syria

INTRODUCTION

Primary breast tuberculosis is a rare form of extrapulmonary tuberculosis even in endemic regions. To our knowledge, this is the first report of Primary breast tuberculosis from Syria.

CASE PRESENTATION

We report a case of a 37-year-old female who admitted to the surgical clinic with a 4-month history of gradually growing mass in the breast. On physical examination there were a palpable mass, painful superficial abscess in her left lateral upper quarter of breast, redness and nipple retraction and ulceration. The patient history and physical examination were clear except for uncontrolled hypothyroidism. Radiological tests including mammography, echography and laboratory investigations were performed. The patient underwent lumpectomy. Histopathologic examination showed caseating Tuberculous Mastitis and a large tuberculous abscess, with no malignancy. Patient was put on anti-tubercular chemotherapy, but recurred after three months with three masses in the same area because she did not adhere to the treatment. Lumpectomy and Anti-tuberculous therapy were repeated again with close follow-up, and the patient recovered.

DISCUSSION

Primary breast tuberculosis forms about 0.025-0.1 % of all surgically treated breast diseases. Diagnosis is based on bacteriological and histological examination. We can get higher accuracy in diagnosis by biopsy such as a core needle or surgical biopsy, surgical biopsy is necessary to confirm the diagnosis of tuberculous mastitis.

CONCLUSION

Tuberculous mastitis is extremely rare variant of extrapulmonary tuberculosis. However, it should be kept in the mind of physicians and pathologists while approaching a breast mass, especially in endemic area.

Acute abdomen due to an infected urachal cyst in a 5-year-old female: case report

The urachus is an embryonic tube that connects the upper portion of the bladder to the umbilicus, and obliterates normally during embryonic development stages forming the median umbilical ligament. Incomplete obliteration of this tube results in many anomalies such as congenital patent urachus, umbilical urachal sinus, vesicourachal diverticulum and urachal cyst. We report in this case a 5-year-old female presented to the Emergency, complaining of generalized abdominal pain, fever, vomiting, and constipation with no umbilical discharge. The clinical presentation accompanied by radiology investigations suggested a case of acute abdomen. We performed an exploratory laparotomy and found a mass above the bladder connected to the umbilicus; we excised the mass and sent a specimen to pathology that confirmed Urachal cyst. Urachal cyst is usually asymptomatic unless it is complicated; depending on our case, we recommend surgical management by complete excision for complicated urachal cyst.

A rare case of incidental finding of GIST during sleeve gastrectomy: Case report

INTRODUCTION

Gastrointestinal stromal tumors (GISTs) is the term used to describe rare stromal neoplasms that are located in the gastrointestinal tract, it most commonly arises in the stomach. GIST is usually asymptomatic and discovered incidentally by Computed Tomography (CT) or Endoscopy.

PRESENTATION OF CASE

We report a case of incidental finding of GIST during Sleeve gastrectomy in a 56 year-old female that presented with a complaint of sever obesity and articular pain in lower limbs. The tumor was not compromising the performance of a save vertical gastric resection, so the resection was done and a mass specimen was sent for pathological examination that confirmed Gist with a low grade of malignancy.

DISCUSSION AND CONCLUSION

As a conclusion, we recommend keeping in mind incidental finding of GIST during abdominal surgeries and especially Sleeve gastrectomy, in order to detect this tumor as earlier as possible and have a good prognosis with a low chance for recurrence.

Evaluation of a quality improvement intervention to reduce anastomotic leak following right colectomy (EAGLE): pragmatic, batched stepped-wedge, cluster-randomized trial in 64 countries

BACKGROUND

Anastomotic leak affects 8 per cent of patients after right colectomy with a 10-fold increased risk of postoperative death. The EAGLE study aimed to develop and test whether an international, standardized quality improvement intervention could reduce anastomotic leaks.

METHODS

The internationally intended protocol, iteratively co-developed by a multistage Delphi process, comprised an online educational module introducing risk stratification, an intraoperative checklist, and harmonized surgical techniques. Clusters (hospital teams) were randomized to one of three arms with varied sequences of intervention/data collection by a derived stepped-wedge batch design (at least 18 hospital teams per batch). Patients were blinded to the study allocation. Low- and middle-income country enrolment was encouraged. The primary outcome (assessed by intention to treat) was anastomotic leak rate, and subgroup analyses by module completion (at least 80 per cent of surgeons, high engagement; less than 50 per cent, low engagement) were preplanned.

RESULTS

A total 355 hospital teams registered, with 332 from 64 countries (39.2 per cent low and middle income) included in the final analysis. The online modules were completed by half of the surgeons (2143 of 4411). The primary analysis included 3039 of the 3268 patients recruited (206 patients had no anastomosis and 23 were lost to follow-up), with anastomotic leaks arising before and after the intervention in 10.1 and 9.6 per cent respectively (adjusted OR 0.87, 95 per cent c.i. 0.59 to 1.30; P = 0.498). The proportion of surgeons completing the educational modules was an influence: the leak rate decreased from 12.2 per cent (61 of 500) before intervention to 5.1 per cent (24 of 473) after intervention in high-engagement centres (adjusted OR 0.36, 0.20 to 0.64; P < 0.001), but this was not observed in low-engagement hospitals (8.3 per cent (59 of 714) and 13.8 per cent (61 of 443) respectively; adjusted OR 2.09, 1.31 to 3.31).

CONCLUSION

Completion of globally available digital training by engaged teams can alter anastomotic leak rates. Registration number: NCT04270721 (http://www.clinicaltrials.gov).

Case report: actinomycosis of the abdominal wall

Primary abdominal wall actinomycosis is rare, but even rarer when it comes to intestinal infiltration; it is usually misdiagnosed as a neoplasm in computed tomography till proved otherwise with pathological examination. We report a 59-year-old diabetic male presented with a year-old abdominal wall mass, diagnosed by pathology after surgical excisional biopsy, and treated with penicillin for 6 months. We recommend consideration of actinomycosis in cases of abdominal wall mass, especially in immunocompromised patients, as a differential diagnosis of neoplastic lesions.

A rare case of peritoneal Xanthogranuloma in a 23-year-old woman

Xanthogranuloma is a very rare tumor when it comes to abdomen. Macroscopically, it is characterized by formation of multiple, golden yellow or bright yellow nodules, whereas histologically, the lesion is predominantly composed of foamy cells mixed with acute and chronic inflammatory cells. We report a case of 23-year-old woman presented to the hospital with chronic constipation, colic abdominal pain and recurrent vomiting. The patient had a history of sigmoid colon volvulus. Radiological investigations showed sigmoid colon elongation, multi-density formations in the left iliac region and pelvis and a small amount of pelvic fluid. Laparoscopy followed by excisional biopsy of the formations were made, and pathological examination showed Xanthogranuloma with no ovarian parenchyma. Hence, Xanthogranuloma should be considered as a differential diagnosis for idiopathic abdominal pain. Laparoscopy and excisional biopsy are suggested procedures when short-term therapy is concerned.

Rapunzel Syndrome in Congenital Mental Retardation Patient Requiring Emergency Laparotomy. Case report

Introduction

When hair accumulates inside the stomach, it causes what is called a Trichobezoar, which leads to a stomach blockage. When the accumulated hair extends into the small intestine, it causes a rare disturbance called Rapunzel syndrome (RS).

Discussion

Affected patients infrequently remain asymptomatic for several years. Symptoms begin while the bezoar increases in size to the point of obstruction, these symptoms are nonspecific like vomiting, nausea, anorexia, asymptomatic abdominal mass and digestive bleeding.

Presentation of case

The authors report an unusual case of a 25 years old young woman who presented with acute abdominal pain and gastrointestinal symptoms. With an upper gastroscopy, the condition was first diagnosed as a Trichobezoar that occupied the stomach. A decision to perform a surgical procedure was taken, only to discover, during the procedure, that the mass was extended to the duodenum and jejunum, thus diagnosing the condition as Rapunzel syndrome. The patient was managed by surgical removal of the huge mass.

Conclusion

Trichobezoar considers as a differential diagnosis for any patient with mental retardation and has gastrointestinal symptoms.

More than 200 hydatid cysts in the lung with a large number of daughter cysts: A rare case report

INTRODUCTION AND IMPORTANCE

Hydatid cysts are a parasitic disease that occurs when humans ingest contaminated food or water containing parasitic eggs. It is a common disease worldwide, especially in cattle breeding areas. In rare cases, the primary cysts contain daughter cysts inside them, as seen in this case.

CASE PRESENTATION

We report a 28-year-old rural woman who presented with a history of sputum-producing cough, dyspnea, hemoptysis, and pain in the right side of the chest. The chest-abdomen-pelvis MSCT revealed a large number of cysts (more than 200 cysts) with daughter cysts inside them in the right lung and mediastinum. The cysts were surgically resected. After surgery, albendazole 200 mg twice a day was prescribed, with monitoring of liver function.

CLINICAL DISCUSSION

In the lungs, hydatid cysts are commonly found in the right lung (50 %), left lung (40 %), and may also be bilateral (10 %). The presence of multivesicular cysts in the lung is very rare. There are two hypotheses concerning the daughter cysts' formation. The first one suggests the effect of repeated mechanical trauma, while the other proposes the defensive mechanism of the patient. Diagnosis of the hydatid cysts in the lung is primarily through radiographic investigations such as Chest X-ray and CT scan. Surgery is still the main method to manage pulmonary hydatid cysts.

CONCLUSION

Although rare, multivesicular hydatid cysts in the lung should be considered, as they can mimic other diseases such as tumors and can cause an embolus in the pulmonary artery.

First reported congenital lumbar hernia with lumbo-costo-vertebral syndrome in the Middle-East: a case report

Congenital lumbar hernia is a rare disease affecting mainly infants. Its association with lumbo-costo-vertebral syndrome (LCVS) is hardly seen in the literature. We present a case of LCVS in a 1-month-old female infant presenting with a soft bulge in left lumbar region. Abdominal X-ray revealed absence of multiple ribs with a mild lumbar scoliosis and defective ninth vertebra. Ultrasonography showed absence lateral abdominal wall muscles in left lumbar region and 2.5 cm diameter lumbar hernia. Primary repair of the adnominal wall defect was performed without meshplasty and no recurrence was reported. We hope to enhance the literature of this rare disease with our case.

Laparoscopic management of a primary gallbladder hydatid cyst with daughter cysts in the common bile duct: Case report

Introduction and importance

Primary Gallbladder hydatid cysts are a very rare phenomenon caused by Echinococcus granulosus. Hydatid cysts usually present as hepatic or pulmonary lesions, but in our case, it presented in the gallbladder with three symptomatic daughter cysts in the CBD. Echinococcus caused by E.granulosus Is the most common parasite causing the disease, accounting for 95% of the cases.

Case presentation

75 - year - old male presented with colic pain, jaundice, itching, vomiting, nausea, insomnia, Positive murphy's sign, and elevated AST and ALT. Total bilirubin was also elevated with no hepatomegaly or splenomegaly.

Clinical discussion

This disease is endemic in Mediterranean countries due to high contact with the host of the parasite the lumen or on the external surface of the gallbladder. Which can come from the portal system or the spreading of brood capsules through the biliary tract.

Conclusion

The method of investigation used was USG, CT, ERCP which are affordable and accessible in low-income countries including Syria. we would like to highlight this rare presentation and the possibility of using laparoscopic surgery.

•

Primary hydatid cyst is usually found in the liver, lungs and brain in our case it presented in the gallbladder and common bile duct which is very rare.

•

We can encounter primary hydatid cyst in unexpected organs especially in countries with high prevalence.

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Jaundice in our case was the main presenting symptom.

•

The role of laparoscopic surgery in treatment because of its less invasive nature and the low spillage possibility. This is the second case treated via laparoscopic surgery.

A late-diagnosed dermoid cyst complicated with a fistula in the left scapular region: a case report

Dermoid cysts are a rare case of developmental abnormality that results in benign tumors, which are classified into three categories based on their cause and appearance. Dermoid cysts tend to present within the first year after birth and are most commonly diagnosed by the age of 5. A 15-year-old girl presented with a complaint of localized, paroxysmal pain and malodorous fluid oozing from the left shoulder for the last 2 weeks. A fistulogram showed an extension of the fistula behind the clavicle and above the scapula with a cystic formation measuring ~2 cm on the upper part of the fistula tract, which called for appropriate surgical intervention. Our case is the first reported dermoid cyst in the left shoulder area associated with a fistula at birth, which is a rare complication since the complications of dermoid cysts differ depending on their location and size.

A unique case of congenital transmesocolic hernia with malrotation in a 25-year-old female: a case report

Congenital transmesocolic hernia of the transverse colon is a very rare type of internal hernia. In addition, intestinal malrotation is very rare in adults. Most of these patients do not have clear clinical manifestations. Incidence of congenital transmesocolic hernia of the transverse colon along with malrotation is an unusual phenomenon in medical literature and clinical practice. Here, we report a unique case of a 25-year-old woman diagnosed with transmesocolic hernia of the transverse colon and malrotation of the small intestine, without any history of trauma or previous surgery. The patient underwent surgery, where the hernia orifice was closed and Ladd’s procedure was performed.

Isolated complete transection of common hepatic artery in a fall accident: a case report

Blunt abdominal trauma is the most frequent external injury to the abdomen, which is rarely due to falling. However, not often does a blunt trauma cause injury to the common hepatic artery. Isolated injury of the common hepatic artery has rarely been reported in the literature. This report describes an unusual case of a falling accident from a height of 5 meters that results in complete transection of the common hepatic artery, yet all other abdominal organs are normal. The case was initially diagnosed by a Focused Assessment with Sonography in Trauma exam and confirmed with an exploratory laparotomy. The successful management would be an end-to-end anastomosis of the dissected artery. We hope we would raise awareness of such injury in order to facilitate its diagnosis and management and improve its outcome.