Summary Background Risk of mortality following surgery in patients across Africa is twice as high as the global average. Most of these deaths occur on hospital wards after the surgery itself. We aimed to assess whether enhanced postoperative surveillance of adult surgical patients at high risk of postoperative morbidity or mortality in Africa could reduce 30-day in-hospital mortality. Methods We did a two-arm, open-label, cluster-randomised trial of hospitals (clusters) across Africa. Hospitals were eligible if they provided surgery with an overnight postoperative admission. Hospitals were randomly assigned through minimisation in recruitment blocks (1:1) to provide patients with either a package of enhanced postoperative surveillance interventions (admitting the patient to higher care ward, increasing the frequency of postoperative nursing observations, assigning the patient to a bed in view of the nursing station, allowing family members to stay in the ward, and placing a postoperative surveillance guide at the bedside) for those at high risk (ie, with African Surgical Outcomes Study Surgical Risk Calculator scores ≥10) and usual care for those at low risk (intervention group), or for all patients to receive usual postoperative care (control group). Health-care providers and participants were not masked, but data assessors were. The primary outcome was 30-day in-hospital mortality of patients at low and high risk, measured at the participant level. All analyses were done as allocated (by cluster) in all patients with available data. This trial is registered with ClinicalTrials.gov , NCT03853824 . Findings Between May 3, 2019, and July 27, 2020, 594 eligible hospitals indicated a desire to participate across 33 African countries; 332 (56%) were able to recruit participants and were included in analyses. We allocated 160 hospitals (13 275 patients) to provide enhanced postoperative surveillance and 172 hospitals (15 617 patients) to provide standard care. The mean age of participants was 37·1 years (SD 15·5) and 20 039 (69·4%) of 28 892 patients were women. 30-day in-hospital mortality occurred in 169 (1·3%) of 12 970 patients with mortality data in the intervention group and in 193 (1·3%) of 15 242 patients with mortality data in the control group (relative risk 0·96, 95% CI 0·69–1·33; p=0·79). 45 (0·2%) of 22 031 patients at low risk and 309 (5·6%) of 5500 patients at high risk died. No harms associated with either intervention were reported. Interpretation This intervention package did not decrease 30-day in-hospital mortality among surgical patients in Africa at high risk of postoperative morbidity or mortality. Further research is needed to develop interventions that prevent death from surgical complications in resource-limited hospitals across Africa. Funding Bill & Melinda Gates Foundation and the World Federati...

Background. There are limited published data describing surgical admissions at a regional hospital level in the South African (SA) context. Objectives. To retrospectively review data from an electronic discharge summary database at a regional SA hospital from 2012 to 2016 to describe the burden of surgical disease by analysing characteristics of the patients admitted. Methods. All discharge summary records for the 4-year period were reviewed after extraction from a database created for the surgery department. Admissions were classified into 5 types: (i) elective surgery or investigations (ESI); (ii) trauma; (iii) burns; (iv) non-traumatic surgical emergencies (NTSE); and (v) unplanned readmission within 30 days. Other variables reviewed were demographic data, the International Statistical Classification of Diseases and Related Health Problems -Version 10 (ICD-10) diagnosis; area of origin; and outcome (death, tertiary referral, discharge). Data were subgrouped into 12-month periods to facilitate trend analysis. Results. Discharge summaries (N=9 805) over the 4-year study period were assessed and 9 799 were included in the analysis. All data were entered by the attending medical personnel. A total of 5 647 male patients (57.6%) and 4 152 female patients (42.4%) were admitted, with a mean age of 43.3 years (95% confidence interval (CI) 43.0 -43.8) and a mean length of stay of 4.9 days (95% CI 4.7 -5.1). Male patients comprised a larger proportion of trauma (83.7%) and burn (63.9%) admissions. The mean length of stay ranged from 3.5 days for elective patients to 9.1 days for burn patients. The most common diagnoses for emergency admissions were appendicitis, peripheral vascular disease and peptic ulcer disease. Common diagnoses for elective admissions were gallstone disease, inguinal hernia, anal fistulas/fissures, and ventral and incisional hernia. The most common cancer diagnoses were of the colorectum, oesophagus, breast and stomach. The overall mortality rate was 2.2%, and highest by subtype was burn patients (6.3%). Trend analysis showed a statistically significant increase in admission for NTSE (p=0.019), trauma (p<0.001) and 30-day readmission rates (p<0.001), with a decrease in admissions for ESI (p=0.001) over the 4 years. Conclusions.A precise understanding of the burden of disease profile is essential for national, provincial and district budgeting and resource allocation. Ongoing surveillance such as that performed in the study provides this critical information.

Surgical site infection (SSI), also known as surgical wound infection, is a major contributor to postoperative morbidity and mortality and is now the most common hospital-associated infection in the USA. [1,2] SSI is a major contributor to healthcare costs through increased length of hospital stay (LoS), antibiotic use, use of diagnostic modalities, surgical procedures and wound care consumables. [3,4] The presence of complicated appendicitis (gangrenous, perforated with local collection or perforated with general peritonism) is a major predictor for the development of SSI. [5-7] In high-income countries (HICs), the incidence of complicated appendicitis varies between 12.8% and 45%. [8,9] The reported risk of developing SSI is 0.6-3.2% for uncomplicated and 3.9-19% for complicated appendicitis. [6,9,10] In low-and middle-income countries (LMICs), barriers to quality surgical care profoundly affect outcomes of patients in need of emergency surgery. [11] Patients in these countries with acute appendicitis often present with significant delay and subsequently more advanced disease, such as general peritonitis or four-quadrant pus. [12] Rates of complicated appendicitis of >60% have been reported, leading to an increase in SSI, reoperation, critical care unit admission and mortality. [13] Determining the effect of time to treatment on the development of SSI in appendicitis is necessary, because time is a variable in the pathogenesis of appendicitis that can be addressed by healthcare providers and systems. Improved access to surgical care and better in-hospital logistics and patient flow may reduce the rate of SSI. Objectives The primary objective of this study was to assess the role that time to definitive surgery plays in the development of SSI in patients undergoing surgery for acute appendicitis. Secondary analyses assessed the effect of time to surgery on the development of complicated appendicitis, and the influence of surgical modality on the development of SSI. Methods A prospective cohort of consecutive patients undergoing surgery for acute appendicitis was recruited over a period of 1 calendar year (2017) at Worcester Regional Hospital, a rural referral centre in Western Cape Province, South Africa. The hospital functions as the primary referral centre for eight district (primary-level) hospitals and a local community health centre. The Department of General Surgery services a public healthcare population projected at ~850 000. [14] Data were prospectively captured for time to definitive operative management, in hours, from symptom onset and hospital admission. Data on age, sex, inflammatory markers, presence of complicated appendicitis and operative modality were collected on admission, together with in-hospital mortality, total length of stay (LoS), and duration of any readmission. The severity of the appendicitis found at operation was classified according to the American Association for the Surgery of Trauma (AAST) grading system for acute appendicitis. [5] This open-access article is distributed under ...

In recent years, international surgical programmes have moved away from vertical service delivery and towards collaborative, capacity-building partnerships. The aim of this review was to provide a map of the current literature on international surgical training partnerships together with an exploration of factors influencing their implementation. Three bibliographic databases were searched for peer-reviewed reports of surgical training partnerships between organizations in high- and low or middle-income countries to July 2018. Reports were sorted in an iterative fashion into groups of similar programmes, and data were extracted to record the intervention strategies, context, financing, reported results and themes around implementation. Eighty-six reports were grouped into five types of programme: full residency training, bi-institutional twinning partnerships, diagonal/sub-specialist programmes, focused interventions or courses and programmes using remote support. Few articles were written from the perspective of the low-middle income partner. Full residency programmes and some diagonal/sub-specialist programmes report numbers trained while twinning partnerships and focused interventions tend to focus on process, partners’ reactions to the programme and learning metrics. Two thematic networks emerged from the thematic synthesis. The first made explicit the mechanisms by which partnerships are expected to contribute to improved access to surgical care and a second identified the importance of in-country leadership in determining programme results. Training partnerships are assumed to improve access to surgical care by a number of routes. A candidate programme theory is proposed together with some more focused theories that could inform future research. Supporting the development of the surgical leadership in low- and middle-income countries is key.

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