Prognostic models for surgical-site infection in gastrointestinal surgery: systematic review.

BACKGROUND: Identification of patients at high risk of surgical-site infection may allow clinicians to target interventions and monitoring to minimize associated morbidity. The aim of this systematic review was to identify and evaluate prognostic tools for the prediction of surgical-site infection in gastrointestinal surgery. METHODS: This systematic review sought to identify original studies describing the development and validation of prognostic models for 30-day SSI after gastrointestinal surgery (PROSPERO: CRD42022311019). MEDLINE, Embase, Global Health, and IEEE Xplore were searched from 1 January 2000 to 24 February 2022. Studies were excluded if prognostic models included postoperative parameters or were procedure specific. A narrative synthesis was performed, with sample-size sufficiency, discriminative ability (area under the receiver operating characteristic curve), and prognostic accuracy compared. RESULTS: Of 2249 records reviewed, 23 eligible prognostic models were identified. A total of 13 (57 per cent) reported no internal validation and only 4 (17 per cent) had undergone external validation. Most identified operative contamination (57 per cent, 13 of 23) and duration (52 per cent, 12 of 23) as important predictors; however, there remained substantial heterogeneity in other predictors identified (range 2-28). All models demonstrated a high risk of bias due to the analytic approach, with overall low applicability to an undifferentiated gastrointestinal surgical population. Model discrimination was reported in most studies (83 per cent, 19 of 23); however, calibration (22 per cent, 5 of 23) and prognostic accuracy (17 per cent, 4 of 23) were infrequently assessed. Of externally validated models (of which there were four), none displayed 'good' discrimination (area under the receiver operating characteristic curve greater than or equal to 0.7). CONCLUSION: The risk of surgical-site infection after gastrointestinal surgery is insufficiently described by existing risk-prediction tools, which are not suitable for routine use. Novel risk-stratification tools are required to target perioperative interventions and mitigate modifiable risk factors.

This study is about finding ways to predict if someone will get an infection after having surgery on their stomach and intestines. If doctors know who is at high risk of getting an infection, they can take steps to prevent it and help the patient recover faster. The researchers looked at all the recent studies that have tried to predict who might get an infection after surgery. They found 23 studies that were good enough to look at in more detail. The researchers found that the studies they looked at were not very good at predicting who might get an infection. Most of the studies did not even check if their predictions were accurate. The few studies that did check were not very good at it. This means that doctors cannot use these predictions to help their patients. This means that doctors need to find better ways to predict who might get an infection after surgery on their stomach and intestines. If they can do this, they can help their patients recover faster and avoid problems like infections.

A Prospective, Observational Cost Comparison of Laparoscopic and Open Appendicectomy in Three Tertiary Hospitals in Nigeria.

BACKGROUND: The clinical benefits of laparoscopic appendicectomy are well recognized over open appendicectomy. However, laparoscopic procedures are not frequently conducted in many low-and middle-income countries (LMICs) for several reasons, including perceived higher costs. The aim of this study was to assess the feasibility and cost of laparoscopic appendicectomy compared to open appendicectomy in Nigeria. METHODS: A multicenter, prospective, cohort study among patients undergoing appendicectomy was conducted at three tertiary hospitals in Nigeria. Data were collected from October 2020 to February 2022 and analyses compared the average healthcare costs at 30 days after surgery. Quantile regression was conducted to identify variables that had an impact on the costs, reported in Nigerian Naira (Naira) and US dollars ($), with standard deviations (SD). FINDINGS: This study included 105 patients, of which 39 had laparoscopic appendicectomy and 66 had open appendicectomy. The average healthcare cost of laparoscopic appendicectomy (147,562 Naira (SD: 97,130) or $355 (SD: 234)) was higher than open appendicectomy (113,556 Naira (SD: 88,559) or $273 (SD: 213)). The average time for return to work was shorter with laparoscopic than open appendicectomy (mean: 8 days vs. 14 days). At the average daily income of $5.06, laparoscopic appendicectomy was associated with 9778 Naira or $24 cost savings in return to work. Further, 5.1% of laparoscopic appendicectomy patients had surgical site infections compared to 22.7% for open appendicectomy. Regression analysis results showed that laparoscopic appendicectomy was associated with $14 higher costs than open appendicectomy, albeit non-significant (p = 0.53). INTERPRETATION: Despite selection bias in this real-world study, laparoscopic appendicectomy was associated with a slightly higher overall cost, a lower societal cost, a lower infection rate, and a faster return to work, compared to open appendicectomy. It is technically and financially feasible, and its provision in Nigeria should be expanded.

Outcomes of gynecologic cancer surgery during the COVID-19 pandemic: an international, multicenter, prospective CovidSurg-Gynecologic Oncology Cancer study.

BACKGROUND: The CovidSurg-Cancer Consortium aimed to explore the impact of COVID-19 in surgical patients and services for solid cancers at the start of the pandemic. The CovidSurg-Gynecologic Oncology Cancer subgroup was particularly concerned about the magnitude of adverse outcomes caused by the disrupted surgical gynecologic cancer care during the COVID-19 pandemic, which are currently unclear. OBJECTIVE: This study aimed to evaluate the changes in care and short-term outcomes of surgical patients with gynecologic cancers during the COVID-19 pandemic. We hypothesized that the COVID-19 pandemic had led to a delay in surgical cancer care, especially in patients who required more extensive surgery, and such delay had an impact on cancer outcomes. STUDY DESIGN: This was a multicenter, international, prospective cohort study. Consecutive patients with gynecologic cancers who were initially planned for nonpalliative surgery, were recruited from the date of first COVID-19-related admission in each participating center for 3 months. The follow-up period was 3 months from the time of the multidisciplinary tumor board decision to operate. The primary outcome of this analysis is the incidence of pandemic-related changes in care. The secondary outcomes included 30-day perioperative mortality and morbidity and a composite outcome of unresectable disease or disease progression, emergency surgery, and death. RESULTS: We included 3973 patients (3784 operated and 189 nonoperated) from 227 centers in 52 countries and 7 world regions who were initially planned to have cancer surgery. In 20.7% (823/3973) of the patients, the standard of care was adjusted. A significant delay (>8 weeks) was observed in 11.2% (424/3784) of patients, particularly in those with ovarian cancer (213/1355; 15.7%; P<.0001). This delay was associated with a composite of adverse outcomes, including disease progression and death (95/424; 22.4% vs 601/3360; 17.9%; P=.024) compared with those who had operations within 8 weeks of tumor board decisions. One in 13 (189/2430; 7.9%) did not receive their planned operations, in whom 1 in 20 (5/189; 2.7%) died and 1 in 5 (34/189; 18%) experienced disease progression or death within 3 months of multidisciplinary team board decision for surgery. Only 22 of the 3778 surgical patients (0.6%) acquired perioperative SARS-CoV-2 infections; they had a longer postoperative stay (median 8.5 vs 4 days; P<.0001), higher predefined surgical morbidity (14/22; 63.6% vs 717/3762; 19.1%; P<.0001) and mortality (4/22; 18.2% vs 26/3762; 0.7%; P<.0001) rates than the uninfected cohort. CONCLUSION: One in 5 surgical patients with gynecologic cancer worldwide experienced management modifications during the COVID-19 pandemic. Significant adverse outcomes were observed in those with delayed or cancelled operations, and coordinated mitigating strategies are urgently needed.

Collaboration in colorectal surgical research.

Surgical research has been under-powered, under-funded and under-delivered for decades. A solution may be to form large research collaborations and thereby enable implementation of successful interventional trials as well as robust international observational studies with thousands of patients. There are many such research collaborations in colorectal surgery, and in this paper we have highlighted the experiences from the West Midlands Research Collaborative (WMRC), the Scandinavian Surgical Outcomes Research Group (SSORG) and the European Society of Coloproctology. With active research networks, it is possible to deliver large, high-quality studies and provide high-level evidence for solving important clinical questions in an efficient and timely manner.

Correction to: Appendicitis as a manifestation of colon cancer: should we image the colon after appendicectomy in patients over the age of 40 years?

The above article originally published with an error present in Table 1 and is now presented correctly in this article.

Appendicitis as a manifestation of colon cancer: should we image the colon after appendicectomy in patients over the age of 40 years?

BACKGROUND: Appendicitis can be secondary to caecal pathology (polyp or cancer). Increasing age is a risk factor for malignancy coexisting with appendicitis. There is an increased coexistence of cancer post-appendicectomy in patients aged 50-54 years. This study investigates whether post-appendicectomy patients aged over 40 years should receive further colorectal imaging and follow-up. METHODS: Retrospective data were collected for 1633 patients aged 40 years and over who underwent appendicectomy in a 10-year period (1st January 2004-31st December 2014). Data were analysed for patients with histological confirmation of acute appendicitis. Incidental appendicular tumours were excluded. RESULTS: One thousand fifty-five (64%) patients had histological confirmation of acute appendicitis (median age 52 years; range 40-96 years). Six hundred three patients (57%) were aged 40-54 years; 452 patients (43%) were aged 55 years or over. Twenty-six (2.5%) patients were investigated post-appendicectomy. Three (11.5%) had caecal pathology: 2 adenocarcinoma, 1 benign caecal polyp. Ten (2.2%) patients aged 55 years or over had caecal pathology. Seven (1.6%) were diagnosed with caecal cancer. No patients below age 54 years were diagnosed with caecal cancer. The incidence of caecal cancer in the study population was 0.66% (40-54.9 years 0%; 55 years and over 1.6%). Patients aged 55 years or over were more likely to develop caecal pathology than patients aged 40-54 years (p = 0.006). The odds ratio of developing caecal pathology was 6.8 times greater (95% CI 1.49-31.29) in people aged 55 years and over. CONCLUSIONS: Patients aged 55 years or over who have undergone appendicectomy should be offered colonoscopy to exclude coexistent caecal pathology.

Impact of socioeconomic deprivation on short-term outcomes and long-term overall survival after colorectal resection for cancer.

PURPOSE: The aim of this study was to assess the effects of socioeconomic deprivation on short-term outcomes and long-term overall survival following major resection of colorectal cancer (CRC) at a tertiary hospital in England. METHOD: This was an observational cohort study of patients undergoing resection for colorectal cancer from January 2010 to December 2017. Deprivation was classified into quintiles using the English Indices of Multiple Deprivation 2010. Primary outcome was overall complications (Clavien-Dindo grades 1 to 5). Secondary outcomes were the major complications (Clavien-Dindo 3 to 5), length of hospital stay and overall survival. Outcomes were compared between most affluent group and most deprived group. Multivariate regression models were used to establish the relationship taking into account confounding variables. RESULTS: One thousand eight hundred thirty-five patients were included. Overall and major complication rates were 44.9% and 11.5% respectively in the most affluent, and 54.6% and 15.6% in the most deprived group. Most deprived group was associated with higher overall complications (odds ratio 1.48, 95% CI 1.13-1.95, p = 0.005), higher major complications (odds ratio 1.49, 1.01-2.23, p = 0.048) and longer hospital stay (adjusted ratio 1.15, 1.06-1.25, p < 0.001) when compared with most affluent group. Median follow period was 41 months (interquartile range 20-64.5). Most deprived group had poor overall survival compared with most affluent, but it was not significant at the 5% level (hazard ratio 1.27, 0.99-1.62, p = 0.055). CONCLUSION: Deprivation was associated with higher postoperative complications and longer hospital stay following major resection for CRC. Its relationship with survival was not statistically significant.

Differences in outcome between patients readmitted to index vs non-index hospital trusts after colorectal resection.

AIM: The clinical consequences of readmission following major surgery in the English National Health Service are unknown. This study aimed to determine differences in outcome between patients readmitted to index vs non-index trusts after major surgery. METHOD: Adult patients who underwent colorectal resection in England in April 2006 to March 2017 were identified in the national Hospital Episodes Statistics dataset. Patients were included if they were readmitted as emergencies within 30 days of initial discharge. The primary outcome measure was all-cause mortality within 90 days of readmission. Comparisons between patients readmitted to index vs non-index trusts were adjusted for confounders using multivariable logistic regression. Rectal resection patients were a planned subgroup. RESULTS: The readmission rate following colorectal resection was 15.1% (54 680/364 481), with 7.1% (3905/54 680) readmitted to a non-index trust. The 90-day mortality following readmission was 7.1% (3874/54 680) overall and 3.9% (652/16 736) in the rectal resection subgroup. The reoperation rate was 19.2% (10 498/54 680) overall and 23.1% (3859/16 736) after rectal resection. Mortality was significantly higher in non-index [10.9% (427/3905)] vs index trusts [6.8% (3447/507 75), adjusted OR 1.50, 95% CI 1.34-1.68, P < 0.001]. There was an annual average of 14.7 excess deaths in non-index trusts; only 1.9 of these followed surgical reoperation. In patients who underwent rectal resection, only 0.3 of the total 1.9 excess deaths each year in non-index trusts followed surgical reoperation. CONCLUSION: Despite a statistical difference, the absolute number of excess deaths attributable to readmission to a non-index trust is very low, particularly amongst patients requiring reoperation.

Integrated surgical academic training in the UK: a cross-sectional survey.

OBJECTIVES: This study aimed to explore variations in the provision of integrated academic surgical training across the UK. DESIGN: This is an online cross-sectional survey (consisting of 44 items with a range of free-text, binomial and 5-point Likert scale responses) developed by the Association of Surgeons in Training. SETTING: A self-reported survey instrument was distributed to academic surgical trainees across the UK (n=276). PARTICIPANTS: 143 (51.9%) responses were received (81% male, median age: 34 years), spanning all UK regions and surgical specialties. Of the 143 trainees, 29 were core trainees (20.3%), 99 were specialty trainees (69.2%) and 15 (10.5%) described themselves as research fellows. RESULTS: The structure of academic training varied considerably, with under a third of trainees receiving guaranteed protected time for research. Despite this, however, 53.1% of the respondents reported to be satisfied with how their academic training was organised. Covering clinical duties during academic time occurred commonly (72.7%). Although most trainees (n=88, 61.5%) met with their academic supervisor at least once a month, six (4.2%) never had an academic supervisory meeting. Most trainees (n=90, 62.9%) occupied a full-time rota slot and only 9.1% (n=13) described their role as 'supernumerary'. Although 58.7% (n=84) of the trainees were satisfied with their clinical competence, 37.8% (n=54) felt that clinical time focused more on service provision than the acquisition of technical skills. 58 (40.6%) had experienced some form of negative sentiment relating to their status as an academic trainee. CONCLUSIONS: Integrated academic training presents unique challenges and opportunities within surgery. This survey has identified variation in the quality of current programmes, meaning that the future provision of integrated surgical academic training should be carefully considered.