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,...

Background: Surgical mortality data are collected routinely in high-income countries, yet virtually no low-or middle-income countries have outcome surveillance in place. The aim was prospectively to collect worldwide mortality data following emergency abdominal surgery, comparing findings across countries with a low, middle or high Human Development Index (HDI).Methods: This was a prospective, multicentre, cohort study. Self-selected hospitals performing emergency surgery submitted prespecified data for consecutive patients from at least one 2-week interval during July to December 2014. Postoperative mortality was analysed by hierarchical multivariable logistic regression.

No abstract

Robotic systems have been shown to improve unicompartmental knee arthroplasty (UKA) component placement accuracy compared to conventional methods when used by experienced surgeons. We aimed to determine whether inexperienced UKA surgeons can position components accurately using robotic assistance when compared to conventional methods and to demonstrate the effect repetition has on accuracy. Sixteen surgeons were randomised to an active constraint robot or conventional group performing three UKAs over three weeks. Implanted component positions and orientations were compared to planned component positions in six degrees of freedom for both femoral and tibial components. Mean procedure time decreased for both robot (37.5 mins to 25.7 mins) (P = 0.002) and conventional (33.8 mins to 21.0 mins) (P = 0.002) groups by attempt three indicating the presence of a learning curve; however, neither group demonstrated changes in accuracy. Mean compound rotational and translational errors were lower in the robot group compared to the conventional group for both components at all attempts for which rotational error differences were significant at every attempt. The conventional group's positioning remained inaccurate even with repeated attempts although procedure time improved. In comparison, by limiting inaccuracies inherent in conventional equipment, robotic assistance enabled surgeons to achieve precision and accuracy when positioning UKA components irrespective of their experience.

Trauma disproportionately affects low- and middle-income countries, many of which do not have the surveillance systems required to design effective prevention and treatment strategies. The aim of this study was to establish such a system at a district hospital in Malawi. Data on all trauma patients presenting to Mulanje District Hospital from 14 April 2013 to 30 December 2014 were collected using a form based on the core minimum data points for injuries recommended by the World Health Organization and an injury severity assessment. A total of 9073 trauma cases were recorded, accounting for 3.4% of patients that presented at the hospital during this period. Of them, 56.6% were boys/men, with the average age being 22.4 (range, 0.6-98 years). Falls (53.2%), animal bites (16.6%), road traffic injuries (11.1%) and assaults (10.2%) were the most prevalent causes, the majority of the former two taking place at home. Of the patients, 94.8% were treated and sent home, 5.0% were admitted and the remaining were either referred elsewhere or died.

No abstract

BackgroundA robust health care system providing safe surgical care to a population can only be achieved in conjunction with access to competent surgical personnel. It has been reported that 5 billion people do not have access to safe, affordable surgical and anaesthesia care when needed. This study aims to fill the existing gap in evidence by quantifying shortfalls in trained personnel delivering safe surgical and anaesthetic care in low- and middle-income countries (LMICs) according to the type of health care facility.MethodsWe conducted secondary analysis of 1323 health facilities, in 35 low- and middle-income countries using facility-based cross-sectional data from the World Health Organization Situational Analysis Tool to Assess Emergency and Essential Surgical Care.ResultsThe majority of surgical and anaesthetic care in LMICs was provided by general doctors (range 13.8–41.1%; mean 27.1%). Non-physicians made up a significant proportion of the surgical workforce in LMICs. 26.76% of the surgical and anaesthetic workforce was provided by clinical medical officers and nurses. Private/NGO/mission hospitals, large, well-resourced institutions had the highest proportion of surgeons compared to any other type of health care facility at 27.92%. This compares to figures of 18.2 and 19.96% of surgeons at health centres and subdistrict/community hospitals, respectively, representing the lowest level of health facility.ConclusionsWe highlight the significant proportion of non-physicians delivering surgical and anaesthetic care in LMICs and illustrate wide variations according to the type of health care facility.

Background A key strategy to building surgical capacity in low income countries involves training care providers, particularly in the interventions highlighted by the Lancet Commission for Global Surgery, including the management of open fractures. This is a common injury, especially in areas with a high incidence of road traffic incidents. The aim of this study was to use a nominal group consensus method to design a course on open fracture management for clinical officers in Malawi. Methods The nominal group meeting was held over two days, including clinical officers and surgeons from Malawi and the UK with various levels of expertise in the fields of global surgery, orthopaedics and education. The group was posed with questions on course content, delivery and evaluation. Each participant was encouraged to suggest an answer and the advantages and disadvantages of each suggestion were discussed before voting through an anonymous online platform. Voting included use of a Likert scale or ranking available options. Ethical approval for this process was obtained from the College of Medicine Research and Ethics Committee Malawi and the Liverpool School of Tropical Medicine. Results All suggested course topics received an average score of greater than 8 out of 10 on a Likert scale and were included in the final programme. Videos was the highest ranking option as a method for delivering pre-course material. The highest ranking methods for each course topic included lectures, videos and practicals. When asked what practical skill should be tested at the end of the course, the highest ranking option was “initial assessment”. Conclusion This work outlines how a consensus meeting can be used to design an educational intervention to improve patient care and outcomes. Through combining the perspectives of both the trainer and trainee, the course aligns both agendas so that it is relevant and sustainable.