EAES, SAGES, and ESCP rapid guideline: bowel preparation for minimally invasive colorectal resection.

BACKGROUND: Variation exists in practice pertaining to bowel preparation before minimally invasive colorectal surgery. A survey of EAES members prioritized this topic to be addressed by a clinical practice guideline. OBJECTIVE: The aim of the study was to develop evidence-informed clinical practice recommendations on the use of bowel preparation before minimally invasive colorectal surgery, through evidence synthesis and a structured evidence-to-decision framework by an interdisciplinary panel of stakeholders. METHODS: This is a collaborative project of EAES, SAGES, and ESCP. We updated a previous systematic review and performed a network meta-analysis of interventions. We appraised the certainty of the evidence for each comparison, using the GRADE and CINeMA methods. A panel of general and colorectal surgeons, infectious diseases specialists, an anesthetist, and a patient representative discussed the evidence in the context of benefits and harms, the certainty of the evidence, acceptability, feasibility, equity, cost, and use of resources, moderated by a GIN-certified master guideline developer and chair. We developed the recommendations in a consensus meeting, followed by a modified Delphi survey. RESULTS: The panel suggests either oral antibiotics alone prior to minimally invasive right colon resection or mechanical bowel preparation (MBP) plus oral antibiotics; MBP plus oral antibiotics prior to minimally invasive left colon and sigmoid resection, and prior to minimally invasive right colon resection when there is an intention to perform intracorporeal anastomosis; and MBP plus oral antibiotics plus enema prior to minimally invasive rectal surgery (conditional recommendations); and recommends MBP plus oral antibiotics prior to minimally invasive colorectal surgery, when there is an intention to localize the lesion intraoperatively (strong recommendation). The full guideline with user-friendly decision aids is available in https://app.magicapp.org/#/guideline/LwvKej . CONCLUSION: This guideline provides recommendations on bowel preparation prior to minimally invasive colorectal surgery for different procedures, using highest methodological standards, through a structured framework informed by key stakeholders. Guideline registration number PREPARE-2023CN045.

Has network meta-analysis resolved the controversies related to bowel preparation in elective colorectal surgery?

AIM: There are discrepancies in the guidelines on preparation for colorectal surgery. While intravenous antibiotics (IV) are usually administered, the use of mechanical bowel preparation (MBP) and/or oral antibiotics (OA) is controversial. A recent network meta-analysis (NMA) demonstrated that the addition of OA reduced incisional surgical site infections (iSSIs) by more than 50%. We aimed to perform a NMA including only the highest quality randomized clinical trials (RCTs) in order to determine the ranking of different treatment strategies and assess these RCTs for methodological problems that may affect the conclusions of the NMAs. METHOD: A NMA was performed according to PRISMA guidelines. RCTs of adult patients undergoing elective colorectal surgery with appropriate antibiotic cover and with at least 250 participants recruited, clear definition of endpoints and duration of follow-up extending beyond discharge from hospital were included. The search included Medline, Embase, Cochrane and SCOPUS databases. Primary outcomes were iSSI and anastomotic leak (AL). Statistical analysis was performed in Stata v.15.1 using frequentist routines. RESULTS: Ten RCTs including 5107 patients were identified. Treatments compared IV (2218 patients), IV + OA (460 patients), MBP + IV (1405 patients), MBP + IV + OA (538 patients) and OA (486 patients). The likelihood of iSSI was significantly lower for IV + OA (rank 1) and MBP + IVA + OA (rank 2), reducing iSSIs by more than 50%. There were no differences between treatments for AL. Methodological issues included differences in definition, assessment and frequency of primary endpoint infections and the limited number of participants included in some treatment options. CONCLUSION: While this NMA supports the addition of OA to IV to reduce iSSI it also highlights unanswered questions and the need for well-designed pragmatic RCTs.

The impact of prolonged delay to loop ileostomy closure on postoperative morbidity and hospital stay: A retrospective cohort study.

AIM: There is increasing evidence that delayed loop ileostomy closure is associated with an increase in postoperative morbidity. In the context of a publicly funded health service with constrained theatre access, we review the impact of delay in loop ileostomy closure. METHOD: A retrospective cohort study of patients undergoing loop ileostomy closure at the Dunedin Public Hospital between 2000-2017 was performed. Cases and complications were identified from the prospectively maintained Otago Clinical Audit database. Patient demographics, ASA score, indications for ileostomy, reasons for delay in closure, length of stay (LOS) after ileostomy closure and complications were collected. LOS and overall complication rate were assessed using univariable and multivariable analyses. RESULTS: A total of 292 patients were included in the study, of whom 74 (25.3%) were waiting for longer than 12 months for ileostomy closure. The overall complication rate was 21.5%. This was 8% up to 90 days, 20% between 90-360 days, 28% between 360-720 days and 54% after 720 days. Delay was associated with an increased risk of any complication (RR 1.06 for every 30 days with stoma, p < 0.001), including Ileus (OR [95% CI] 1.06 [1.00-1.11], p = 0.024). Overall mean LOS was 5.9 days (range 1-63), being 4.6 days up to 180 days, 5.6 between 180-720 days and 8.7 after 720 days. LOS significantly increased with increasing stoma duration (p = 0.04). CONCLUSION: Increasing time with loop ileostomy is detrimental for patients, being associated with an increase in complication rates, and is detrimental for hospitals due to increased length of stay. Resources should be allocated for timely closure of loop ileostomies.

Short-term high-intensity interval training improves fitness before surgery: A randomized clinical trial.

PURPOSE: Improving cardiopulmonary reserve, or peak oxygen consumption( V ˙ O2peak ), may reduce postoperative complications; however, this may be difficult to achieve between diagnosis and surgery. Our primary aim was to assess the efficacy of an approximate 14-session, preoperative high-intensity interval training(HIIT) program to increase V ˙ O2peak by a clinically relevant 2 ml·kg-1 ·min-1 . Our secondary aim was to document clinical outcomes. METHODOLOGY: In this prospective study, participants aged 45-85 undergoing major abdominal surgery were randomized to standard care or 14 sessions of HIIT over 4 weeks. HIIT sessions involved approximately 30 min of stationary cycling. Interval training alternated 1 min of high (with the goal of reaching 90% max heart rate at least once during the session) and low/moderate-intensity cycling. Cardiopulmonary exercise testing(CPET) measured the change in V ˙ O2peak from baseline to surgery. Clinical outcomes included postoperative complications, length of stay(LOS), and Short Form 36 quality of life questionnaire(SF-36). RESULTS: Of 63 participants, 46 completed both CPETs and 50 completed clinical follow-up. There was a significant improvement in the HIIT group's mean ± SD V ˙ O2peak (HIIT 2.87 ± 1.94 ml·kg1 ·min-1 vs standard care 0.15 ± 1.93, with an overall difference of 2.73 ml·kg1 ·min-1 95%CI [1.53, 3.93] p < 0.001). There were no statistically significant differences between groups for clinical outcomes, although the observed differences consistently favored the exercise group. This was most notable for total number of complications (0.64 v 1.16 per patient, p = 0.07), SF-36 physical component score (p = 0.06), and LOS (mean 5.5 v 7.4 days, p = 0.07). CONCLUSIONS: There was a significant improvement in V ˙ O2peak with a four-week preoperative HIIT program. Further appropriately powered work is required to explore the impact of preoperative HIIT on postoperative clinical outcomes.

Role for colorectal teams to support non-colorectal teams to improve clinical outcomes and adherence to ERAS guidelines for segmental colectomy: a cohort study.

BACKGROUND: To identify whether compliance with Enhanced Recovery After Surgery (ERAS) Society recommendations is associated with length of stay (LOS) in a New Zealand hospital for patients undergoing segmental colectomy in mixed acute and elective general surgery wards. METHODS: Consecutive elective colorectal surgeries (n = 770) between October 2012 and February 2019 were audited. Patients with non-segmental colectomies, multi-organ surgeries, LOS > 14 days, and those who died were excluded. Logistic regression was used to determine the relationship between patient demographics, compliance with ERAS guidelines, and suboptimal LOS (> 4 days). RESULTS: Analysis included 376 patients. Age, surgery prior to 2014, surgical approach, non-colorectal surgical team, operation type, and complications were significantly associated with suboptimal LOS. Non-compliance with ERAS recommendations for laparoscopy [OR 8.9, 95% CI (4.52, 19.67)], removal of indwelling catheters (IDC) [OR 3.14, 95% CI (1.85, 5.51)], use of abdominal drains [OR 4.27, 95% CI (0.99, 18.35)], and removal of PCA [OR 8.71, 95% CI (1.78, 157.27)], were associated with suboptimal LOS (univariable analysis). Multivariable analysis showed that age, surgical team, late removal of IDC, and open approach were independent predictors of suboptimal LOS. CONCLUSIONS: Non-compliance with ERAS guidelines for laparoscopic approach and early removal of IDC was higher among procedures performed by non-colorectal surgery teams, and was also associated with adverse postoperative events and suboptimal LOS. This study demonstrates the importance of the surgical team's expertise in affecting surgical outcomes, and did not find significant independent associations between most individual ERAS guidelines and suboptimal LOS once adjusting for other factors.

Incidence and significance of postoperative complications occurring between discharge and 30 days: a prospective cohort study.

BACKGROUND: Accurate documentation of complications is fundamental to clinical audit and research. While it is established that accurate diagnosis of surgical site infection (SSI) requires follow-up for 30 days; for other complications, there are minimal data quantifying their importance between discharge and 30 days. METHODS: In this prospective cohort study, inpatients undergoing general or vascular surgery were reviewed daily for complications by the medical team and a research fellow. A standardized telephone questionnaire was performed 30 days following surgery. All complications were documented and classified according to severity. RESULTS: A total of 237 of 388 patients who completed the telephone survey developed a complication, including 77 who developed a complication for the first time after discharge from hospital. Overall 135 (33%) of a total of 405 complications were identified after discharge. These complications included 36 of 63 (57%) SSI, 6 of 12 small bowel obstructions, and three of four major thromboembolic events and a number of space SSI, urinary infections, functional gastrointestinal problems, and pain management problems. Cardiac, respiratory, and neurologic complications were mainly diagnosed in hospital. Of the 135 "postdischarge" complications, 89 were managed in the community and 46 (34%) resulted in admission to hospital, including seven which required a major intervention. There was one death. CONCLUSIONS: One-third of complications occurred after discharge, and one-third of these resulted in readmission to hospital. Research and audit based on inpatient data alone significantly underestimates morbidity rates. Discharge planning should include contingency plans for managing problems commonly diagnosed after discharge form hospital.

Association of Preoperative High-Intensity Interval Training With Cardiorespiratory Fitness and Postoperative Outcomes Among Adults Undergoing Major Surgery: A Systematic Review and Meta-Analysis.

Importance: Preoperative high-intensity interval training (HIIT) is associated with improved cardiorespiratory fitness (CRF) and may improve surgical outcomes. Objective: To summarize data from studies comparing the association of preoperative HIIT vs standard hospital care with preoperative CRF and postoperative outcomes. Data Sources: Data sources included Medline, Embase, Cochrane Central Register of Controlled Trials Library, and Scopus databases with no language constraints, including abstracts and articles published before May 2023. Study Selection: The databases were searched for randomized clinical trials and prospective cohort studies with HIIT protocols in adult patients undergoing major surgery. Thirty-four of 589 screened studies met initial selection criteria. Data Extraction and Synthesis: A meta-analysis was performed according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Data were extracted by multiple independent observers and pooled in a random-effects model. Main Outcomes and Measures: The primary outcome was change in CRF, as measured by either peak oxygen consumption (V̇o2 peak) or 6-Minute Walk Test (6MWT) distance. Secondary outcomes included postoperative complications; hospital length of stay (LOS); and changes in quality of life, anaerobic threshold, and peak power output. Results: Twelve eligible studies including 832 patients were identified. Pooled results indicated several positive associations for HIIT when compared with standard care either on CRF (V̇o2 peak, 6MWT, anaerobic threshold, or peak power output) or postoperative outcomes (complications, LOS, quality of life), although there was significant heterogeneity in study results. In 8 studies including 627 patients, there was moderate-quality evidence of significant improvement in V̇o2 peak (cumulative mean difference, 2.59 mL/kg/min; 95% CI, 1.52-3.65 mL/kg/min; P < .001). In 8 studies including 770 patients, there was moderate-quality evidence of a significant reduction in complications (odds ratio, 0.44; 95% CI, 0.32-0.60; P < .001). There was no evidence that HIIT differed from standard care in hospital LOS (cumulative mean difference, -3.06 days; 95% CI, -6.41 to 0.29 days; P = .07). The analysis showed a high degree of heterogeneity in study outcomes and an overall low risk of bias. Conclusions and Relevance: The results of this meta-analysis suggest that preoperative HIIT may be beneficial for surgical populations through the improvement of exercise capacity and reduced postoperative complications. These findings support including HIIT in prehabilitation programs before major surgery. The high degree of heterogeneity in both exercise protocols and study results supports the need for further prospective, well-designed studies.

Strategies for Antibiotic Administration for Bowel Preparation Among Patients Undergoing Elective Colorectal Surgery: A Network Meta-analysis.

Importance: There are discrepancies in guidelines on preparation for colorectal surgery. While intravenous (IV) antibiotics are usually administered, the use of mechanical bowel preparation (MBP), enemas, and/or oral antibiotics (OA) is controversial. Objective: To summarize all data from randomized clinical trials (RCTs) that met selection criteria using network meta-analysis (NMA) to determine the ranking of different bowel preparation treatment strategies for their associations with postoperative outcomes. Data Sources: Data sources included MEDLINE, Embase, Cochrane, and Scopus databases with no language constraints, including abstracts and articles published prior to 2021. Study Selection: Randomized studies of adults undergoing elective colorectal surgery with appropriate aerobic and anaerobic antibiotic cover that reported on incisional surgical site infection (SSI) or anastomotic leak were selected for inclusion in the analysis. These were selected by multiple reviewers and adjudicated by a separate lead investigator. A total of 167 of 6833 screened studies met initial selection criteria. Data Extraction and Synthesis: NMA was performed according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines. Data were extracted by multiple independent observers and pooled in a random-effects model. Main Outcomes and Measures: Primary outcomes were incisional SSI and anastomotic leak. Secondary outcomes included other infections, mortality, ileus, and adverse effects of preparation. Results: A total of 35 RCTs that included 8377 patients were identified. Treatments compared IV antibiotics (2762 patients [33%]), IV antibiotics with enema (222 patients [3%]), IV antibiotics with OA with or without enema (628 patients [7%]), MBP with IV antibiotics (2712 patients [32%]), MBP with IV antibiotics with OA (with good IV antibiotic cover in 925 patients [11%] and with good overall antibiotic cover in 375 patients [4%]), MBP with OA (267 patients [3%]), and OA (486 patients [6%]). The likelihood of incisional SSI was significantly lower for those receiving IV antibiotics with OA with or without enema (rank 1) and MBP with adequate IV antibiotics with OA (rank 2) compared with all other treatment options. The addition of OA to IV antibiotics, both with and without MBP, was associated with a reduction in incisional SSI by greater than 50%. There were minimal differences between treatments in anastomotic leak and in any of the secondary outcomes. Conclusions and Relevance: This NMA demonstrated that the addition of OA to IV antibiotics were associated with a reduction in incisional SSI by greater than 50%. The results support the addition of OA to IV antibiotics to reduce incisional SSI among patients undergoing elective colorectal surgery.

American Society of Anesthesiologists classification of physical status as a predictor of wound infection.

BACKGROUND: Wound infection occurs when bacterial contamination overcomes the hosts' defences against bacterial growth. Wound categories are a measurement of wound contamination. The American Society of Anesthesiologists (ASA) classification of physical status may be an effective indirect measurement of the hosts' defence against infection. This study examines the association between the ASA score of physical status and wound infection. METHODS: A retrospective review of a prospective study of antibiotic prophylaxis was carried out. Patients with a documented ASA score who received optimal prophylactic antibiotics were included. The anaesthetist scored the ASA classification of physical status in theatre. Other risk factors for wound infection were also documented. Patients were assessed up to 30 days postoperatively. RESULTS: Of 1013 patients there were 483 with a documented ASA score. One hundred and one may not have received optimal prophylaxis, leaving a database of 382 patients. There were 36 wound infections (9.4%). Both the ASA classification of physical status (P = 0.002) and the wound categories (P = 0.034) significantly predicted wound infection. The duration of surgery, patient's age, acuteness of surgery and the organ system being operated on did not predict wound infection. On logistic regression analysis the ASA score was the strongest predictor of wound infection. CONCLUSION: When effective prophylactic antibiotics were used the ASA classification of physical status was the most significant predictor of wound infection.

Accuracy of the Surgeons' Clinical Prediction of Postoperative Major Complications Using a Visual Analog Scale.

BACKGROUND: Although the risk factors that contribute to postoperative complications are well recognized, prediction in the context of a particular patient is more difficult. We were interested in using a visual analog scale (VAS) to capture surgeons' prediction of the risk of a major complication and to examine whether this could be improved. METHODS: The study was performed in 3 stages. In phase I, the surgeon assessed the risk of a major complication on a 100-mm VAS immediately before and after surgery. A quality control questionnaire was designed to check if the VAS was being scored as a linear scale. In phase II, a VAS with 6 subscales for different areas of clinical risk was introduced. In phase III, predictions were completed following the presentation of detailed feedback on the accuracy of prediction of complications. RESULTS: In total, 1295 predictions were made by 58 surgeons in 859 patients. Eight surgeons did not use a linear scale (6 logarithmic, 2 used 4 categories of risk). Surgeons made a meaningful prediction of major complications (preoperative median score 40 mm for complications v. 22 mm for no complication, P < 0.001; postoperative 46 mm v. 21 mm, P < 0.001). In phase I, the discrimination of prediction for preoperative (0.778), postoperative (0.810), and POSSUM (Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity) morbidity (0.750) prediction was similar. Although there was no improvement in prediction with a multidimensional VAS, there was a significant improvement in the discrimination of prediction after feedback (preoperative, 0.895; postoperative, 0.918). CONCLUSION: Awareness of different ways a VAS is scored is important when designing and interpreting studies. Clinical assessment of major complications by the surgeon was initially comparable to the prediction of the POSSUM morbidity score and improved significantly following the presentation of clinically relevant feedback.

Experience with the use of vacuum dressings in the management of acute enterocutaneous fistulas.

High-output enterocutaneous fistulas involving an open abdominal wound are a difficult management problem. We report our experience on the use of vacuum dressings. The potential benefits, problems and new recommendations for the use of vacuum dressings in the management of enterocutaneous fistulas are discussed.

Duodenal obstruction associated with an abdominal aortic aneurysm.

Aortoduodenal syndrome is a rare clinical entity characterized by an upper gastrointestinal obstruction in association with an abdominal aortic aneurysm. The exact mechanism of obstruction is unknown. We present a case of aortoduodenal syndrome and discuss the interplay of the aneurysm and duodenum in the development of the duodenal obstruction.

A comparison of the prophylactic efficacy of ceftriaxone and cefotaxime in abdominal surgery.

BACKGROUND: Although ceftriaxone (R) and cefotaxime (C) are highly effective antibiotics, few studies have directly compared their prophylactic efficacy. METHODS: In a prospective, randomized, double blind study of 1,013 patients undergoing abdominal surgery, the prophylactic use of ceftriaxone and cefotaxime were compared. Intravenous cephalosporin, 1 g, was given at induction of anesthesia, with intravenous metronidazole, 500 mg, also being given for colorectal surgery. RESULTS: The difference in wound infection (R 8%, C 12%, P <0.05) was due to appendicectomies not receiving metronidazole, (R 6%, C 18%, P <0.03) and was no longer present when these cases were excluded from analysis (R 8%, C 10%). Of note chest and urinary tract infection (R 6%, C 11%, P <0.02) and "any" infection (R 20%, C 27%, P <0.05) were reduced with ceftriaxone. CONCLUSIONS: Both antibiotics provide comparable wound prophylaxis as long as metronidazole is added for colorectal and appendiceal surgery. Ceftriaxone may be more versatile having the additional apparent benefits of reducing other postoperative infections, being less dependent on metronidazole as an adjunct and providing a more effective prophylactic cover against Staphylococcus aureus.

Training outside of the box.

BACKGROUND: Developments in surgical training in Australasia allow for individualization of training to suit individual requirements. One uncommon career track is medical aid or missionary surgery in the developing world. It is difficult to receive appropriate training for this type of surgical practice in Australasia. The present paper describes a novel approach to preparing for this kind of work by spending a 6 month rotation in a mission hospital in rural East Africa. METHODS: The surgical trainee spent 5 months working at Kijabe Hospital in Kenya. This is a large mission hospital with a busy general surgical workload and adequate staffing for training. RESULTS: The trainee performed 214 major cases, in a broad range of general surgery, under appropriate supervision. He also took part in regular educational sessions, surgical audit, and helped to develop one of East Africa's pioneering laparoscopic surgical -programmes. CONCLUSIONS: The present paper demonstrates that it is possible for Australasian trainees to gain useful experience in the rural African environment, in hospitals where appropriate surgical supervision is available.

Diagnosis and management of isolated pancreatic tuberculosis: recent experience and literature review.

The increased reporting of tuberculosis of the pancreas is related to a worldwide increase in tuberculosis and an increase in emigration from countries where tuberculosis is endemic into countries where more sophisticated healthcare and radiological imaging are available. Three recent cases of pancreatic tuberculosis in Auckland, New Zealand, emphasize that tuberculosis should now be included in the differential diagnosis of a pancreatic mass. Diagnostic indicators include emigration from, or recent travel to, a country where tuberculosis is endemic, the association of a pancreatic mass with fever, the presence of abdominal pain and a cystic pancreatic mass in a younger male. Radiological appearances might be similar to a mucinous cystic neoplasm or could show a pancreatic mass with involvement of peripancreatic lymph nodes or a mass centred in a peripancreatic lymph node. When the diagnosis is suspected an human immunodeficiency virus test and a comprehensive screening for tuberculosis at other sites should be performed. If tuberculosis is unable to be diagnosed then pancreatic biopsy and culture is indicated. Endoscopic ultrasound with fine needle aspiration for cytology is likely to become the preferred technique. Most patients have an excellent clinical response to standard antituberculosis regimens.

Accuracy of the surgeons' clinical prediction of perioperative complications using a visual analog scale.

BACKGROUND: The ability to predict who will develop perioperative complications remains difficult because the etiology of adverse events is multifactorial. This study examines the preoperative and postoperative ability of the surgeon to predict complications and assesses the significance of a change in prediction. METHODS: This was a prospective study of 1013 patients. The surgeon assessed the risk of a major complication on a 100-mm visual analog scale (VAS) immediately before and after surgery. When the VAS score was changed, the surgeon was asked to document why. Patients were assessed up to 30 days postoperatively. RESULTS: Surgeons made a meaningful preoperative prediction of major complications (median score = 27 mm vs. 19 mm, p < 0.01), with an area under the receiver operating characteristic curve of 0.74 for mortality, 0.67 for major complications, and 0.63 for all complications. A change in the VAS score postoperatively was due to technical reasons in 74% of stated cases. An increased VAS score identified significantly more complications, but the improvement in the discrimination was small. When included in a multivariate model for predicting postoperative complications, the surgeon's VAS score functioned as an independent predictive variable and improved the predictive ability, goodness of fit, and discrimination of the model. CONCLUSIONS: Clinical assessment of risk by the surgeon using a VAS score independently improves the prediction of perioperative complications. Including the unique contribution of the surgeon's clinical assessment should be considered in models designed to predict the risk of surgery.

Using cost of infection as a tool to demonstrate a difference in prophylactic antibiotic efficacy: a prospective randomized comparison of the pharmacoeconomic effectiveness of ceftriaxone and cefotaxime prophylaxis in abdominal surgery.

The purpose of this study was to test the hypothesis that cost, as well as frequency of infection, could be used to demonstrate a difference in the performance of prophylactic antibiotics. In a prospective, randomized, double-blind study, 1013 patients undergoing abdominal surgery were given 1 g of intravenous ceftriaxone (R) or cefotaxime (C) at induction of anesthesia, and an additional 500 mg of metronidazole for colorectal surgery. Infection was checked for during the hospital stay and at 30 days postoperatively. The inpatient, outpatient, and community costs of infection were prospectively collected. The frequency of wound infection for appendectomies when additional metronidazole was not administered was greater with cefotaxime (R 6%, C 18%, p < 0.05), but the cost of infection was the same (average cost R $994 +/- SD $1101, C $878 +/- $1318). For all other procedures, the frequency of wound infection was similar (R 8%, C 10%), but the cost was less with ceftriaxone (R $887 +/- $1743, C $2995 +/- $6592, p < 0.05). Ceftriaxone decreased the frequency but not the cost of chest and urinary infection (frequency R 6%, C 11%, p < 0.02, cost R $1273 +/- 2338, C $1615 +/- 4083). Differences in both the frequency and cost of all infection are also presented. Ceftriaxone decreased either the frequency or the cost of different postoperative infections. The cost of infection can increase the discriminatory power of trials comparing antibiotic effectiveness.

Trauma in rural Kenya.

BACKGROUND: Trauma in Africa is an increasingly significant problem. The aims of this study were to document the epidemiology and clinical management of trauma in a rural Kenyan hospital and from this to highlight important areas for the medical training of doctors managing trauma in similar situations. METHODS: Prospective audit of 202 consecutive trauma patients admitted to Kijabe Hospital. RESULTS: The mean patient age was 31, 77% were males. The median Injury Severity Score (ISS) was nine. The median distance to hospital was 60 km, with a 9 h delay in presentation. Injury mechanisms included road traffic accidents 52%, fall 22%, assaults 13% and burns 6%. The main injuries were limb fractures, soft tissue injuries, head injury and haemo/pneumothorax. Common interventions included fracture management, wound debridement, chest drain insertion, blood transfusion and skin grafting. The overall mortality rate was 3.5%. CONCLUSION: With appropriate resources and training, good trauma outcomes are possible. The importance of access to hospital care and orthopaedic training are highlighted.