Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

Background: Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. Methods: This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231. Findings: Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p < 0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p < 0·001). Interpretation: Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication

MARK&apos;s Quadrant scoring system: a symptom-based targeted screening tool for gastric cancer

Abstract Background Gastric cancer is notably one of the leading causes of cancer-related death in the world. In Malaysia, these patients present in the advanced stage, thus narrowing the treatment options and making the surgery nearly impossible for successful curative resection. Failure to identify high-risk patients and delay in diagnostic endoscope procedure contributed to the delay in diagnosis. The aim of the study was to develop and validate a scoring system (MARK&apos;s Quadrant) which can identify symptomatic patients who are at risk for gastric cancer

SHIITAKE MUSHROOM AS A CAUSE OF BOWEL OBSTRUCTION

Shiitake mushroom, claimed to have major health benefits. It is a popular ingredient in east Asian cuisine. Given that mushrooms are rich in dietary fiber, the undigested fiber can act as a bezoar and may cause small bowel obstruction. Bezoar-induced small bowel obstructions are rare and herein we report a case of intestinal obstruction caused by shiitake mushroom. An elderly patient was admitted with features of intestinal obstruction. Preoperative imaging showed dilated small bowel with suspicious mass in ileum. Patient underwent laparotomy and undigested shiitake mushroom was retrieved at enterotomy. Clinical awareness of the mushroom induced intestinal obstruction and early use abdominal computed tomography (CT) are essential for prompt diagnosis and treatment.</jats:p

Tumour necrosis factor-α(-308) polymorphism and the risk of gastric cancer: A meta- analysis and trial sequential analysis

Abstract Background: Numerous studies have reported that polymorphisms in the tumour necrosis factor-alpha (TNF-a-308) gene are implicated in susceptibility to gastric cancer. However, individual genetic association studies that assessed the relationship between TNF-a- 308 and the risk of gastric cancer showed inconclusive results. The objective of this study was to synthesis evidence on the association between polymorphisms in the TNF-a-308 and gastric cancer risk. Methods: This is a meta-analysis of genetic association studies. We searched relevant case-control studies, assessing TNF- 308 polymorphisms and gastric cancer in health-related electronic databases. The methodological quality of included studies was assessed by the Newcastle-Ottawa quality assessment scale. The strength of association was calculated as odds ratios (ORs) with its 95% confidence intervals (CIs). Pooled ORs and 95 % CIs were estimated using random-effect model or fixed effect model, based on between-study heterogeneity. We analysed the strength of association under dominant, recessive, additive and allele models. Multiple subgroup analyses including ethnic groups, HWE status, study quality were done for robustness of the estimates. Publication bias was detected by inspection of funnel plot asymmetry. Results: A total of 33 studies, comprising 7695 patients and 12327 controls were identified. Based on the studies that met HWE, significant association was found between this polymorphisms and gastric cancer risk under dominant model (OR 1.2, 95%CI 1.1-1.3, I 2 :37%), recessive model OR 1.27, 95%CI 1.0-1.62, I 2 :0%) and additive model (OR 1.31, 95%CI 1.08-1.32, I 2 :0%). The TSA plot indicated the analyses was with the required information size. There was no publication bias. In the subgroup analysis by ethnicity, the ethnic groups and the quality of studies had impact on the estimates. Conclusions: The findings suggest that TNF-α-308 gene polymorphism plays an important role as host genetic factor predisposing to gastric carcinogenesis, and it would be useful for a screening marker.</jats:p

Study Protocol of an Open Labelled Randomised Controlled Trial of Perioperative Oral Nutrition Supplement in Breast and Colorectal Cancer Patients Undergoing Elective Surgery

Abstract Background: While it is well established that perioperative use of oral nutrition supplement (ONS) improves nutrition status among severely malnourished surgical cancer patients, the evidence requires further substantiation for non-severely malnourished patients with cancer. This protocol paper presents the rationale and design of a randomised controlled trial to evaluate the effectiveness of preoperative as well as an extended 3-month postoperative use of ONS on nutritional and clinical outcomes among patients undergoing elective surgery for breast and colorectal cancer. Methods: Patients with primary breast and colorectal cancer undergoing elective surgery are recruited from two tertiary hospitals. Eligible patients are assigned into one of the three intervention arms: i) Group SS will receive ONS in addition to their normal diet up to 14 days preoperatively and postoperatively up to discharge, ii) Group SS-E will receive ONS in addition to their normal diet up to 14 days preoperatively, postoperatively up to discharge and for an extended 3 months after discharge and iii) Group DS will receive ONS in addition to their normal diet postoperatively up to discharge from the hospital. The ONS is a standard formula fortified with lactium to aid in sleep for recovery. The primary endpoints include changes in weight, body mass index (BMI), serum albumin and prealbumin levels, while secondary endpoints are body composition (muscle and fat mass), muscle strength (handgrip strength), energy and protein intake, sleep quality, haemoglobin, inflammatory markers (transferrin, Hs-CRP, interleukin-6), stress marker (saliva cortisol), length of hospital stay and postoperative complication rate. Discussion: This trial is expected to provide evidence on whether perioperative supplementation in breast and colorectal cancer patients presenting with high BMI and not severely malnourished but undergoing the stress of surgery, would be beneficial in terms of nutritional, and clinical outcomes. Trial registration: ClinicalTrial.gov with the identifier: NCT04400552. Registered on 22 May 2020, retrospectively registered.</jats:p

Can We Use Peer-Assisted Learning to Teach Basic Surgical Skills?

Background: It is reported that medical students do not receive adequate opportunities to learn surgical skill and are at risk of being unable to perform simple surgical procedures safely. The usefulness of peer-assisted learning (PAL) as a tool to assist in delivering surgical skills training is worth exploring. Methods: This is a randomised single blinded controlled trial. Fourth-year students from the university’s Surgical Society were asked to volunteer as peer tutors and those in 3rd-year were asked to undertake surgical skills training. A cohort of 35 students were selected and randomised to receive basic surgical skills training conducted either by faculty members or peers. The students’ performance of basic suturing skills was assessed using a checklist, through directly observed procedural skills (DOPS) technique. The assessment was conducted by faculty blinded to the training. Students’ perception to surgical skills training was assessed using a questionnaire survey. Results: The suturing and knotting skills of students learned from their peers was comparable to that acquired from faculty. The students’ perceived that their peers could conduct surgical skills training similar to their faculty. Conclusion: PAL approach for basic surgical skills training is as effective as faculty-led training. PAL has the potential to optimise the delivery of surgical skills training in undergraduate medical education.</jats:p

Effects of Perioperative Oral Nutrition Supplementation in Malaysian Patients Undergoing Elective Surgery for Breast and Colorectal Cancers—A Randomised Controlled Trial

This study aimed to investigate the effectiveness of preoperative and an extended 90-days postoperative use of ONS among patients undergoing elective surgery for breast and colorectal cancers. Ninety-one patients were randomised into (i) Group SS received ONS up to 14 days preoperatively and postoperatively up to discharge, (ii) Group SS-E received ONS up to 14 days preoperatively, postoperatively up to discharge and for an extended 90-days after discharge and (iii) Group DS received ONS postoperatively up to discharge. Preoperatively, SS had significantly higher body weight (66.1 ± 15.3 kg vs. 62.5 ± 12.0 kg, p = 0.010) and BMI (26.8 ± 6.8 kg/m2 vs. 26.1 ± 6.7 kg/m2, p = 0.022) than DS when adjusted for baseline values. Postoperatively, SS-E had significantly higher handgrip strength (26 ± 9 kgF vs. 24 ± 6 kgF, p = 0.044) than DS at 90-days post-discharge after adjusted for preoperative values. At 90-days post-discharge, the proportions of patients in SS with albumin &lt; 35 g/d, CAR ≥ 0.1, mPINI ≥ 0.4, mGPS score 1 or 2 were significantly reduced while in SS-E, the reduction in proportions of patients with high hsCRP and mPINI ≥ 0.4 was significant compared to upon discharge. Preoperative ONS had modest benefits in attenuating weight loss whilst postoperative supplementation up to 90-days post-discharge improved handgrip strength and inflammatory prognostic markers.</jats:p

Effects of Perioperative Oral Nutrition Supplementation in Malaysian Patients Undergoing Elective Surgery for Breast and Colorectal Cancers—A Randomised Controlled Trial

This study aimed to investigate the effectiveness of preoperative and an extended 90-days postoperative use of ONS among patients undergoing elective surgery for breast and colorectal cancers. Ninety-one patients were randomised into (i) Group SS received ONS up to 14 days preoperatively and postoperatively up to discharge, (ii) Group SS-E received ONS up to 14 days preoperatively, postoperatively up to discharge and for an extended 90-days after discharge and (iii) Group DS received ONS postoperatively up to discharge. Preoperatively, SS had significantly higher body weight (66.1 ± 15.3 kg vs. 62.5 ± 12.0 kg, p = 0.010) and BMI (26.8 ± 6.8 kg/m2 vs. 26.1 ± 6.7 kg/m2, p = 0.022) than DS when adjusted for baseline values. Postoperatively, SS-E had significantly higher handgrip strength (26 ± 9 kgF vs. 24 ± 6 kgF, p = 0.044) than DS at 90-days post-discharge after adjusted for preoperative values. At 90-days post-discharge, the proportions of patients in SS with albumin < 35 g/d, CAR ≥ 0.1, mPINI ≥ 0.4, mGPS score 1 or 2 were significantly reduced while in SS-E, the reduction in proportions of patients with high hsCRP and mPINI ≥ 0.4 was significant compared to upon discharge. Preoperative ONS had modest benefits in attenuating weight loss whilst postoperative supplementation up to 90-days post-discharge improved handgrip strength and inflammatory prognostic markers