Background Most clinical guidelines are developed by high‐income country institutions with little consideration given to either the evidence base for interventions in low‐ and middle‐income countries (LMICs), or the specific challenges LMIC health systems may face in implementing recommendations. The aim of this study was to prioritize topics for future global surgery guidelines and then to develop a guideline for the top ranked topic. Methods A Delphi exercise identified and prioritized topics for guideline development. Once the top priority topic had been identified, relevant existing guidelines were identified and their recommendations were extracted. Recommendations were shortlisted if they were supported by at least two separate guidelines. Following two voting rounds, the final recommendations were agreed by an international guideline panel. The final recommendations were stratified by the guideline panel as essential (baseline measures that should be implemented as a priority) or desirable (some hospitals may lack these resources at present, in which case they should plan for future implementation). Results Prevention of surgical‐site infection (SSI) after abdominal surgery was identified as the highest priority topic for guideline development. The international guideline panel reached consensus on nine essential clinical recommendations for prevention of SSI. These included recommendations concerning preoperative body wash, use of prophylactic antibiotics, decontamination of scrub teams' hands, use of antiseptic solutions for surgical site preparation and perioperative supplemental oxygenation. In addition, three desirable clinical recommendations and four recommendations for future research were agreed. Conclusion This process led to the development of a global surgery guideline for the prevention of SSI that is both clinically relevant and implementable in LMICs.

Background In sub‐Saharan Africa, surgical access is limited by an inadequate surgical workforce, lack of infrastructure and decreased care‐seeking by patients. Delays in treatment can result from delayed presentation (pre‐hospital), delays in transfer (intrafacility) or after arrival at the treating centre (in‐hospital delay; IHD). This study evaluated the effect of IHD on mortality among patients undergoing emergency general surgery and identified factors associated with IHD. Methods Utilizing Malawi's Kamuzu Central Hospital Emergency General Surgery database, data were collected prospectively from September 2013 to November 2017. Included patients had a diagnosis considered to warrant urgent or emergency intervention for surgery. Bivariable analysis and Poisson regression modelling was done to determine the effect of IHD (more than 24 h) on mortality, and identify factors associated with IHD. Results Of 764 included patients, 281 (36·8 per cent) had IHDs. After adjustment, IHD (relative risk (RR) 1·68, 95 per cent c.i. 1·01 to 2·78; P = 0·045), generalized peritonitis (RR 4·49, 1·69 to 11·95; P = 0·005) and gastrointestinal perforation (RR 3·73, 1·25 to 11·08; P = 0·018) were associated with a higher risk of mortality. Female sex (RR 1·33, 1·08 to 1·64; P = 0·007), obtaining any laboratory results (RR 1·58, 1·29 to 1·94; P < 0·001) and night‐time admission (RR 1·59, 1·32 to 1·90; P < 0·001) were associated with an increased risk of IHD after adjustment. Conclusion IHDs were associated with increased mortality. Increased staffing levels and operating room availability at tertiary hospitals, especially at night, are needed.

BACKGROUND Traumatic brain injury (TBI) is a leading cause of death and disability worldwide. The incidence of TBI in low- and middle-income countries (LMICs) is disproportionately high, with an associated increased risk of mortality from TBI relative to high-income countries. Although computed tomography is the diagnostic method of choice, this is often unavailable in LMICs. Exploratory burr holes may provide a suitable choice for diagnosis and treatment of TBI. METHODS We performed a retrospective review of prospectively collected data at KCH, a tertiary care center in Lilongwe, Malawi. All trauma patients presenting between June 2012 and July 2015 with a deteriorating level of consciousness and localizing signs and who underwent exploratory burr holes were included. Additionally, we included all patients admitted with TBI, requiring higher-level care during 2011. No patients underwent exploratory burr hole during this time. We performed logistic regression to identify predictors of mortality in the total population of TBI patients. RESULTS Among the 241 patients who presented to KCH with TBI requiring higher-level care, the total mortality was 16.4%. More than half (163, or 68%) underwent exploratory burr hole with a mortality of 6.8%. Mortality in patients who did not undergo exploratory burr hole was 43.9%. Upon adjusted logistic regression, not undergoing exploratory burr hole significantly increased the odds of mortality (odds ratio = 12.0, P = 0.000, 95% confidence interval = 4.48–31.9). CONCLUSION Exploratory burr holes remain an important diagnostic and therapeutic procedure for TBI in LMICs. Exploratory burr hole technique should be integrated into general surgery education to attenuate TBI-related mortality.

Brief Reports should be submitted online to www.editorialmanager.com/ amsurg. (See details online under ''Instructions for Authors''.) They should be no more than 4 double-spaced pages with no Abstract or sub-headings, with a maximum of four (4) references. If figures are included, they should be limited to two (2). The cost of printing color figures is the responsibility of the author.In general, authors of case reports should use the Brief Report format. Surgical Outcomes of Acute Appendicitis in High-Middle-and Low-Income CountriesAcute appendicitis (AA) is the most common gastrointestinal surgical emergency. Interestingly, a recent study has showed that the incidence of AA in the 21st century has stabilized in high-income countries but has increased in low-and middle-income countries. 1 The epidemiological transition in addition to the increasing urbanization of the society requires a health system that is capable of delivering emergency surgery. Unfortunately, the ability to deliver essential surgical care varies significantly among high-, middleand low-income countries. We hypothesized that there is significantly increased morbidity and mortality after AA in resource-poor settings. Therefore, we aimed to compare the outcomes of AA in patients managed in a high-income (United States), in a middle-income (Argentina), and in a low-income country (Malawi).We performed a retrospective analysis of a consecutive series of adult patients ($18 years old) who underwent appendectomy for suspected AA between January 1, 2013, and December 31, 2015, at three different institutions: University of North Carolina (UNC) in the United States, Hospital Alemán of Buenos Aires (HA) in Argentina, and Kamuzu Central Hospital (KCH) in Malawi. Collected data variables included demographic characteristics, diagnostic imaging modality obtained, time from symptom onset to presentation at the hospital, time from presentation to surgical intervention, type of surgery performed, hospital length of stay (LOS), and mortality.Categorical variables were compared by chi-squared test and continuous variables with the Student's t test.

Sex disparities exist within the general surgery population at KCH in Lilongwe, Malawi. Fewer women present with surgical problems, and women experience delays in presentation, longer lengths of stay, and undergo fewer operations. Future studies to determine mortality in the community and driving factors of sex disparities will provide more insight.