Patients exposed to a surgical safety checklist experience better postoperative outcomes, but this could simply reflect wider quality of care in hospitals where checklist use is routine.

Background: Primary amputation (stump closure) for diabetic foot sepsis is perceived to have a higher re-amputation rate due to stump sepsis. A guillotine amputation with elective stump closure is widely practised due to the lower risk of stump sepsis and re-amputation. Aims: To provide an epidemiological analysis of the spectrum of disease and outcomes of primary amputation for diabetic foot sepsis in a regional rural hospital. Methods: A prospective cohort study of 100 patients who underwent surgery for diabetic foot sepsis over a 5-year period was undertaken at Madadeni Provincial Hospital, in northern KwaZulu-Natal. Demographic data, co-morbid profile, radiographic features, anatomical level of vascular occlusion and type of surgery performed were recorded. The Wagner classification (Wag) was used to classify disease severity. Outcome measures included length of hospital stay, in-hospital mortality and re-amputation rates. Results: Of the 100 patients, females (n = 50) accounted for 50% of admissions. The median age was 61 years (range: 29 to 80 years). Most patients presented with advanced disease: Wag 5, n = 71 (71%); Wag 4, n = 20 (20%); Wag 3, n = 7 (7%); Wag 2, n = 2 (2%). The anatomic levels of vascular occlusion comprised: aortoiliac disease n = 2 (2%), femoropopliteal n=21(21%) and tibioperoneal disease n = 77 (77%). The following surgical procedures were undertaken: above knee amputation (AKA), n = 35 (35%); below knee amputation (BKA), n = 46 (46%); transmetatarsal amputation (TMA), n = 8 (8%); toe ectomy, n = 8 (8%) and debridement, n = 3 (3%). The re-amputation rate to above knee amputation was n = 2/46 (4.3%). All AKA stumps healed completely. The overall in-hospital mortality was n = 7 (7%) and median length of hospital stay was 7.8 ± 3.83 days. Conclusion: Most patients present with advanced disease requiring a major amputation. A definitive one stage primary amputation is a safe and effective procedure for diabetic foot sepsis with distinct advantages of a short hospital stay, low reamputation rates and mortality. A guillotine amputation should be reserved for physiologically unstable patients.

Background The Clavien–Dindo classification is perhaps the most widely used approach for reporting postoperative complications in clinical trials. This system classifies complication severity by the treatment provided. However, it is unclear whether the Clavien–Dindo system can be used internationally in studies across differing healthcare systems in high‐ (HICs) and low‐ and middle‐income countries (LMICs). Methods This was a secondary analysis of the International Surgical Outcomes Study (ISOS), a prospective observational cohort study of elective surgery in adults. Data collection occurred over a 7‐day period. Severity of complications was graded using Clavien–Dindo and the simpler ISOS grading (mild, moderate or severe, based on guided investigator judgement). Severity grading was compared using the intraclass correlation coefficient (ICC). Data are presented as frequencies and ICC values (with 95 per cent c.i.). The analysis was stratified by income status of the country, comparing HICs with LMICs. Results A total of 44 814 patients were recruited from 474 hospitals in 27 countries (19 HICs and 8 LMICs). Some 7508 patients (16·8 per cent) experienced at least one postoperative complication, equivalent to 11 664 complications in total. Using the ISOS classification, 5504 of 11 664 complications (47·2 per cent) were graded as mild, 4244 (36·4 per cent) as moderate and 1916 (16·4 per cent) as severe. Using Clavien–Dindo, 6781 of 11 664 complications (58·1 per cent) were graded as I or II, 1740 (14·9 per cent) as III, 2408 (20·6 per cent) as IV and 735 (6·3 per cent) as V. Agreement between classification systems was poor overall (ICC 0·41, 95 per cent c.i. 0·20 to 0·55), and in LMICs (ICC 0·23, 0·05 to 0·38) and HICs (ICC 0·46, 0·25 to 0·59). Conclusion Caution is recommended when using a treatment approach to grade complications in global surgery studies, as this may introduce bias unintentionally.

A 22-year-old man sustained a strangulation-type injury to the neck, with bilateral blunt carotid artery injuries detected on computed tomography (CT) angiography. His Glasgow Coma Score was 15/15, and he was managed conservatively with therapeutic low-molecular-weight heparin and antiplatelet therapy. A repeat CT angiogram 6 weeks later showed complete resolution of an intimal flap, and he demonstrated no neurological deterioration. There are no definitive management guidelines regarding this type of injury, and our report emphasises the role of conservative anticoagulation therapy in the management of this rare condition.