Patients exposed to a surgical safety checklist experience better postoperative outcomes, but this could simply reflect wider quality of care in hospitals where checklist use is routine.

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Background: Hartmann's procedure is performed in patients who are not candidates for immediate reestablishment of colonic continuity. A shrunken rectal stump poses a great challenge at the time of its reversal. Objective: To determine the factors [level of inferior mesenteric artery (IMA) ligation and duration prior to Hartmann's reversal] contributing to a shrunken rectal stump. The value of imaging and success rate of the technique used in the Hartmann's reversal were also assessed. Methods: A retrospective analysis of 36 patients who underwent Hartmann's procedure and reversal between 2012 and 2014 was performed. Patient demographic profile, initial pathology, operation setting, level of IMA ligation, complications, duration prior to reversal, imaging modality, state of rectal stump, outcome, and reversal technique were documented. Results: Thirty-six patients were considered for reversal of Hartmann's procedure. In 95.5% of subjects who underwent a high IMA ligation, proximal rectum stricture and short, shrunken rectal stumps were noted. Patients who underwent reversal after 6 months had a significant incidence of a short shrunken rectal stump (n ¼ 19; 82.6%). The percentage of successful outcomes in the reversal of the short rectal stump using the stapling technique was 93.8% (n ¼ 27). Twenty-six patients who underwent barium enema correlated strongly with the operation findings.

Background The Clavien–Dindo classification is perhaps the most widely used approach for reporting postoperative complications in clinical trials. This system classifies complication severity by the treatment provided. However, it is unclear whether the Clavien–Dindo system can be used internationally in studies across differing healthcare systems in high‐ (HICs) and low‐ and middle‐income countries (LMICs). Methods This was a secondary analysis of the International Surgical Outcomes Study (ISOS), a prospective observational cohort study of elective surgery in adults. Data collection occurred over a 7‐day period. Severity of complications was graded using Clavien–Dindo and the simpler ISOS grading (mild, moderate or severe, based on guided investigator judgement). Severity grading was compared using the intraclass correlation coefficient (ICC). Data are presented as frequencies and ICC values (with 95 per cent c.i.). The analysis was stratified by income status of the country, comparing HICs with LMICs. Results A total of 44 814 patients were recruited from 474 hospitals in 27 countries (19 HICs and 8 LMICs). Some 7508 patients (16·8 per cent) experienced at least one postoperative complication, equivalent to 11 664 complications in total. Using the ISOS classification, 5504 of 11 664 complications (47·2 per cent) were graded as mild, 4244 (36·4 per cent) as moderate and 1916 (16·4 per cent) as severe. Using Clavien–Dindo, 6781 of 11 664 complications (58·1 per cent) were graded as I or II, 1740 (14·9 per cent) as III, 2408 (20·6 per cent) as IV and 735 (6·3 per cent) as V. Agreement between classification systems was poor overall (ICC 0·41, 95 per cent c.i. 0·20 to 0·55), and in LMICs (ICC 0·23, 0·05 to 0·38) and HICs (ICC 0·46, 0·25 to 0·59). Conclusion Caution is recommended when using a treatment approach to grade complications in global surgery studies, as this may introduce bias unintentionally.