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,...

EditorialHiatal hernias refer to the condition where intra-abdominal structures herniate into the mediastinum through the oesophageal hiatus. They occur in about 10% of the population. Hiatal hernias are classified in 4 types. Type I or sliding hernia represents 85%-90% of all hiatal hernias. It results from laxity and loss of coherence of the phreno-oesophageal membrane. The gastro-oesophageal junction (GOJ) is displaced above the diaphragm while the fundus remains below the GOJ. Hiatal hernias type II, III and IV or collectively known as paraesophageal hernias represent about 10%-15% of hiatal hernias. Type II hernia results from a localized defect in the phrenooesophageal membrane. The gastric fundus herniates into the mediastinum, while the GOJ remains fixed to the preaortic fascia and the median arcuate ligament. Type III paraoesophageal hernias have elements of both types I and II and have both the GOJ and the fundus herniating through the hiatus. Type IV hiatus hernia is associated with a large defect in the diaphragm defined by the presence of organs other than the stomach in the hernia sac commonly being the transverse colon, spleen, pancreas or small bowel.Paraoesophageal hernia is a condition mainly seen in the elderly population. In most large series, presentation with a median age of 65 to 75 years appears to be the rule [1]. Risk factors for developing hiatal hernia include age greater than 50, BMI>25 and male gender [2]. About 50% of cases are asymptomatic and the hernia is an incidental finding on imaging or endoscopy. In sliding hernias reflux symptoms such as heartburn and regurgitation are more frequent; whilst in paraoesophagheal hernias common symptoms include epigastric or substernal pain, postprandial fullness, dysphagia, nausea, vomiting and dyspnoea. Microcytic anaemia can be present secondary to erosions of the gastric mucosa. Acute symptoms due to gastric outlet obstruction/ gastric volvulus, uncontrolled bleeding, strangulation, perforation, and respiratory compromise are indications for urgent surgery.Hiatus hernia can be an incidental finding on a chest X-ray where the gastric bubble can be seen in the chest. On barium swallow the presence of more than 2 cm separation between the B ring (level of squamocolumnar junction) and the diaphragm suggests a sliding hiatus hernia. If a B ring is not evident on barium swallow (absent in 85% of individuals), the demonstration of at least three rugal folds traversing the diaphragm is diagnostic of a sliding hiatus hernia [3]. In paraoesophageal hernias there is evidence of the fundus herniating into the mediastinum. On endoscopy a sliding hernia is defined as a greater than 2 cm distance between the squamocolumnar junction and the diaphragmatic impression on the stomach [3]. In paraoesophageal hernias the hernia can be visualised on retroflexion (J manoeuvre) of the endoscope that reveals a portion of the stomach, herniating upward through the diaphragm, adjacent to the endoscope [3]. Another indirect indicator of paraoesophageal hernia that sh...

From our study it is clear that experience of first-year training doctors in laparoscopic surgeryis low. Most respondents had very little teaching or hands-on experience in laparoscopic skills as undergraduates. At training level, again there was little dedicated teaching. Conclusion This study shows that the current training in laparoscopic surgery both in medical school and foundation training is not optimal. Basic skills can be taught with relative ease and these skills are directly transferable to the operating theatre environment. We propose that changes must be made to the training programme to better prepare junior doctors.

Post-esophagectomy gastro-bronchial fistula (GBF) has significant morbidity and mortality. Management of GBF remains non standardized due to its rarity and limited available evidence. Reoperation and surgical repair have been the main approach. More recently, multimodal endoscopic treatment is gaining popularity as primary treatment option due to its relatively non invasiveness, increasing evidence of success rate, and reduced morbidity. We present a case series of post-esophagectomy GBF managed endoscopically using over-thescope-clip (OTSC). A dedicated, prospective, and contemporaneous regional upper gastrointestinal cancer database was searched to identify postesophagectomy GBF from January 2015 to December 2017. Clinical notes and investigation images of identified cases were analyzed. Three patients developed post-esophagectomy GBF during the study period. The mean age of patients was 53. The mean time of GBF diagnosis was 233 days (range: 20-608).Two patients had endoscopic stent placement prior to OTSC application. Primary technical success was achieved in all patients. No adverse events were reported. Two patients had complete healing of GBF and the mean healing time was 15 days (range: 6-24). One patient who had significant co-morbidities (peripheral arterial disease, diabetes, hepatitis C, rheumatoid arthritis, and heavy smoker) developed a persistent leak of GBF and died from a cardiac event. GBF and its surgical treatment are associated with high morbidity and mortality. We present this case series where two out of three patients with GBF were successfully treated with this modality. Endoscopic therapy incorporating OTSC placement is a feasible option in the management of postesophagectomy GBF. Further studies are required to understand and establish its role in the treatment algorithm of post-esophagectomy GBF.

Background Totally minimally invasive oesophagectomy although challenging to perform has garnered popularity in the surgical treatment of oesophageal cancer. Advanced laparoscopic surgical skills are needed with the construction of the intra-thoracic anastomosis in the case of a 2-stage procedure being the rate-limiting step. We aim to report our initial experience and short-term outcomes of totally minimally invasive 3-stage and 2-stage oesophagectomies for cancer. Methods From January 2016 when the minimally invasive oesophagectomy programme was implemented in our Unit, to December 2017, 65 consecutive cases underwent either a 2-stage or a 3-stage oesophagectomy for cancer. In all cases a radical 2-field lymph node dissection was performed. All were performed in a prone position and in the 3-stage oesophagectomies, superior mediastinal lympadenectomy was additionally performed. In the 2-stage cases an end-to-side esophago-gastric anastomosis was constructed in two layers with barbed knotless suture (V-LocTM). Results Male: female was 4:1 with a mean age of 66.44 years (IQR, 43–82). n = 53 were 2-stage and 12 were 3-stage oesophagectomies. Thirty five (53.8%) had neoadjuvant chemotherapy and 30(46.2%) went straight to surgery. There were no open conversions. No feeding jejunostomies were placed routinely. Complete resection (R0) rate was 61.54% (40/65) with a mean lymph node harvest of 28 (IQR, 11–68). Five (7.6%) anastomotic leaks were diagnosed (4 in 2-stage and 1 in 3-stage oesophagectomies), with 1(1.5%) of them (in the 2-stage group) being subclinical requiring no intervention. Furthermore, 1(1.5%) chyle leak and 1(1.5%) gastric staple line leak were also observed. Pulmonary complications were reported in 13.8% of cases and cardiac complications arose in 1.5%. Seven (10.8%) anastomotic strictures were also noted that were treated with endoscopic balloon dilatation. Mean hospital stay was 13 days and 30-day mortality rate was 4.62%. Conclusion Implementation of a minimally invasive oesophagectomy program in our high-volume tertiary centre is yielding good initial results. Vast previous experience in the field is of paramount importance. Hand-sewn intrathoracic anastomosis during 2-stage procedures is feasible and with repetitively good outcomes. Disclosure All authors have declared no conflicts of interest.