SummaryBackgroundSurgical 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.MethodsThis 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.FindingsBetween 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).InterpretationCountries 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.FundingDFID-MRC-Wellcome Trust Joint Global Health Trial Development Grant,...

Trichobezoar is an intraluminal mass formed from the accumulation of undigested hair. It is a rare condition that is typically seen in young females with trichophagia and trichotillomania. When not recognized, it may present with complications such as obstruction, ulceration and in some rare cases, perforation. While most trichobezoar perforations are located in the stomach, however, duodenal perforation has not been reported before. We report a case of a 13-year-old girl who presented to the emergency with signs and symptoms of peritonitis and perforated viscus. Radiological investigation revealed a large heterogenous intraluminal mass with mottled gas pattern suspicious of bezoar. Oral contrast was seen tracking from the gastric pylorus into the peritoneum suggestive of a perforation. The girl was brought to theatre for emergency laparotomy and a trichobezoar was found extending from the stomach down to the level of D1. There is a perforation in D1 on its antero-superior surface measuring 1×1 cm. The bezoar was removed via a gastrostomy and the perforation was primarily repaired and patched with omentum. Post operatively, her recovery was complicated with wound breakdown and was subsequently discharged after 1.5 months of hospitalization with outpatient referral for psychiatry consults.

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Intravascular tumour extension can occur in many different types of cancer. Those with the highest tendency include renal cell carcinoma, adrenal cortical carcinoma and hepatocellular carcinoma. Inferior vena cava (IVC) tumour thrombus in gynaecological malignancy is rarely reported. We present a report on a female patient with extensive IVC tumour thrombus (intravenous leiomyomatosis) with concurrent intrauterine leiomyomatosis. She underwent a single-stage procedure, involving laparotomy and a sternotomy to remove her pelvic tumour, as well as the intracaval and intracardiac thrombus. The clinical presentation and management of this rare tumour will be detailed in this case report.

Intussusception is a common surgical problem among pediatric age group, but the same cannot be said in their adult counterparts. While the disease process is similar in both age groups, the etiopathology and hence the management of this condition differs significantly. In this report, we present a case of an adult female with an ileo-ileal intussusception secondary to a small bowel lipoma, followed by a discussion on the difference of clinical features and management between adults and pediatrics.

Appendicitis, being one of the most common surgical problems, is often diagnosed clinically. The typical clinical sign elicited from a patient suffering from acute or perforated appendicitis includes: Rebound tenderness, Rovsing sign, Obturator sign, Psoas sign, and tenderness over the right iliac fossa. Cholecystitis, another common surgical problem, typically presents with tenderness over the right hypochondrium, and the typical sign associated with this condition is positive Murphy’s sign. In this report, we describe how a subhepatic perforated appendicitis can mimic acute cholecytstitis, both clinically and radiologically in an adult patient.