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,...

Spontaneous colocutaneous diverticular fistula presenting as perianal abscessA 76-year-old man presented with a recurrent perianal abscess, following 1 month of diarrhoea, perianal pain and reduced appetite. Absence of an anal fistula and the high extent of the abscess cavity prompted a magnetic resonance imaging scan, which demonstrated a tract extending from sigmoid colon to the ischioanal abscess. Colonoscopy was performed to confirm diverticular disease and exclude malignancy. The patient underwent an elective laparoscopic-assisted anterior resection and temporary defunctioning loop ileostomy.Bilateral ureteric stents were inserted due to hydronephrosis from left ureteric obstruction and to assist intraoperative identification of ureters. Laparoscopic mobilization of the splenic flexure was undertaken first. Dissection of the sigmoid colon and mesorectum was difficult due to surrounding fibrosis and residual purulent inflammation, and was performed through a lower midline incision. Subsequent resection, anastomosis and loop ileostomy proceeded uneventfully. The patient was discharged on post-operative day 16, having had issues with high stoma output.Diverticular colocutaneous fistulae are rare, and usually follow operation or percutaneous drainage of diverticular abscesses. Spontaneous diverticular colocutaneous fistulae, especially to the perineum are even rarer, with only four cases found in the literature since 2000. [1][2][3][4] Elective operations for diverticular fistulae are usually difficult. They are often performed open due to issues with abdominal access and difficulties identifying dissection planes. In our case, laparoscopic mobilization of the splenic flexure reduced the required extent of the midline wound. Ureteric stents were vital to preservation of the ureters while dissecting out the fistula, and for treatment of the hydronephrosis.Spontaneous colocutaneous diverticular fistula presenting with perianal abscess is exceedingly rare. An intra-abdominal source of sepsis should be considered in recurrent perianal abscess without anal fistula. Anticipation of a difficult dissection should prompt consideration of ureteric stents, but a laparoscopic approach, at least initially, is feasible. References 1. Amor IB, Kassir R, Bachir E, Katharina H, Debs T, Gugenheim J. Perforated diverticulitis of the sigmoid colon revealed by a perianal fistula. Int. J. Surg. Case Rep. 2015; 8c: 73-5. 2. Chadwick T, Katti A, Arthur J. Sigmoid-gluteal fistula: a rare complication of fistulating diverticular disease. J. Surg. Case Rep. 2017; 2017: rjw237. 3. Evaristo-Mendez G, Sanchez-Hernandez AT, Melo-Velazquez A, Ventura-Sauceda FA, Sepulveda-Castro RR. Sigmoido-buttock fistula by diverticulitis: report of a rare complication. Cir. Cir. 2013; 81: 158-62. 4. Fehmer T, Citak M, Schildhauer TA. Sigmoido-gluteal fistulaa rare complication in clinically asymptomatic chronic diverticulitis. Acta Chir.

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Blunt thoracic aortic injury (BTAI) is an uncommon yet serious diagnosis in trauma patients, with high on-scene mortality. BTAI typically occurs from rapid deceleration such as in motor vehicle collisions or high-altitude falls shearing the aorta just proximal to the ligamentum arteriosum. We report a case of a man in his 50s falling from a height of 15 m who presented hypotensive with retrosternal chest pain. Mobile chest X-ray showed a widened mediastinum with left-sided haemothorax. CT revealed a contained free aortic rupture just inferior to the origin of the left subclavian artery with bleeding into the mediastinum and left pleural space. The patient underwent urgent thoracic endovascular aortic repair (TEVAR) but arrested on-table due to a left-sided tension haemothorax requiring chest-drain decompression and haemostatic resuscitation. After return of spontaneous circulation, TEVAR was successfully performed. BTAI is a dynamic process; hence, timely imaging and minimally invasive surgical treatment are key to patients surviving grade III and IV aortic injuries.