Management of COMPlicAted intra-abdominal collectionS after colorectal Surgery (COMPASS): protocol for a multicentre, observational, prospective international study of drain placement practices in colorectal surgery

Catalysing global surgery: a meta-research study on factors affecting surgical research collaborations with Africa

INTRODUCTION

In December 2019, the COVID-19 pandemic highlighted the urgent need for rapid collaboration, research, and interventions. International research collaborations foster more significant responses to rapid global changes by enabling international, multicentre research, decreasing biases, and increasing study validity while reducing overall research time and costs. However, there has been low uptake of collaborative research by African institutions and individuals.

AIM

To systematically review facilitating factors and challenges to collaborative surgical research studies conducted in Africa.

METHODOLOGY

A meta-research review using PubMed®/MEDLINE and Embase on surgical collaboration in Africa from 1st of January 2011 to 31st of September 2021 in accordance to PRISMA guidelines. Surgical studies by collaborative groups involving African authors and sites were included (55 papers). Data on the study period, geographical regions, and research scope, facilitating factors, and challenges were extracted from the studies retrieved from the search.

RESULTS

Most of the collaborations in Africa occurred with European institutions (76%). Of the 54 African countries, 63% (34/54) participated in surgical collaborations. The highest collaboration frequency occurred in South Africa (11%) and Nigeria (8%). However, most publications originated from Eastern Africa (43%). Leveraging synergies between high- and low- to middle-income countries (LMICs), well-defined structures, and secure data platforms facilitated collaboration. However, the underrepresentation of collaborators from LMICs was a significant challenge.

CONCLUSION

Available literature provides critical insights into the facilitating factors and challenges of research collaboration with Africa. However, there is a need for a detailed prospective study to explore the themes highlighted further.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO 2022 CRD42022352115 .

Safety and efficacy of intraperitoneal drain placement after emergency colorectal surgery: An international, prospective cohort study

AIM

Intraperitoneal drains are often placed during emergency colorectal surgery. However, there is a lack of evidence supporting their use. This study aimed to describe the efficacy and safety of intraperitoneal drain placement after emergency colorectal surgery.

METHOD

COMPlicAted intra-abdominal collectionS after colorectal Surgery (COMPASS) is a prospective, international, cohort study into which consecutive adult patients undergoing emergency colorectal surgery were enrolled (from 3 February 2020 to 8 March 2020). The primary outcome was the rate of intraperitoneal drain placement. Secondary outcomes included rate and time-to-diagnosis of postoperative intraperitoneal collections, rate of surgical site infections (SSIs), time to discharge and 30-day major postoperative complications (Clavien-Dindo III-V). Multivariable logistic and Cox proportional hazards regressions were used to estimate the independent association of the outcomes with drain placement.

RESULTS

Some 725 patients (median age 68.0 years; 349 [48.1%] women) from 22 countries were included. The drain insertion rate was 53.7% (389 patients). Following multivariable adjustment, drains were not significantly associated with reduced rates (odds ratio [OR] = 1.56, 95% CI: 0.48-5.02, p = 0.457) or earlier detection (hazard ratio [HR] = 1.07, 95% CI: 0.61-1.90, p = 0.805) of collections. Drains were not significantly associated with worse major postoperative complications (OR = 1.26, 95% CI: 0.67-2.36, p = 0.478), delayed hospital discharge (HR = 1.11, 95% CI: 0.91-1.36, p = 0.303) or increased risk of SSIs (OR = 1.61, 95% CI: 0.87-2.99, p = 0.128).

CONCLUSION

This is the first study investigating placement of intraperitoneal drains following emergency colorectal surgery. The safety and clinical benefit of drains remain uncertain. Equipoise exists for randomized trials to define the safety and efficacy of drains in emergency colorectal surgery.

Study management strategies to optimize student- and trainee-led collaborative research

The collaborative research model is a powerful approach to answering surgical research questions that empowers and inspires medical students and trainees. The Opioid PrEscRiptions and usage After Surgery (OPERAS) study is a student- and trainee-led international multi-centre prospective cohort study developed in Australia and Aotearoa New Zealand. In this article, we will discuss (i) how the OPERAS study was conceptualized and structured; (ii) the channels through which information and education were communicated to collaborators; (iii) how data was stored in a secure and user-friendly fashion and (iv) the lessons learned and expected goals for the future. We aim to describe how collaborative research studies can be designed to support early career researchers to make valuable contributions to the literature.

Acute PresentatiOn of coLorectaL cancer - an internatiOnal snapshot (APOLLO): Protocol for a prospective, multicentre cohort study

AIM

The primary aim of the study is to describe the variation in the operative and nonoperative management of emergency presentations of colon and rectal cancer in an international cohort. Secondary aims will be to develop a risk prediction model for mortality and primary anastomosis and validate risk criteria of large bowel obstruction (LBO) in patients with previously known colorectal cancer undergoing neoadjuvant chemotherapy or awaiting elective surgery.

METHOD

This prospective, multicentre audit will be conducted via the student- and trainee-led EuroSurg Collaborative network internationally over 2023 with 90-day follow-up. Data will be collected on consecutive adult patients presenting to the hospital in an unplanned and urgent manner with colorectal cancer (CRC) due to malignant LBO, perforation, CRC-related haemorrhage, or other related reasons. Primary outcome is 90-day mortality. Secondary outcomes include rates of stomas, primary anastomosis, stenting, preoperative imaging, and complications or readmissions.

CONCLUSION

This protocol describes the methodology for the first international audit on the management of acutely presenting CRC. This study will utilise a large collaborative network with robust data validation and assurance strategies. APOLLO will provide a comprehensive understanding of current practice, develop risk prediction tools in this setting, and validate existing trial results.

Opioid PrEscRiptions and usage After Surgery (OPERAS): protocol for a prospective multicentre observational cohort study of opioid use after surgery

INTRODUCTION

Postoperative pain is common and frequently addressed through opioid analgesia. This practice must balance the benefits of achieving adequate pain relief against the harms of adverse effects such as opioid-induced ventilatory impairment and opioid use disorder. This student and trainee-led collaborative study aims to investigate and compare the prescription versus consumption of opioids at 7 days postdischarge after common surgical procedures and their impact on patient-reported outcomes regarding postoperative pain.

METHODS AND ANALYSIS

This is a prospective multicentre observational cohort study of surgical patients in Australia, Aotearoa New Zealand and select international sites, conducted by networks of students, trainees and consultants. Consecutive adult patients undergoing common elective and emergency general, orthopaedic, gynaecological and urological surgical procedures are eligible for inclusion, with follow-up 7 days after hospital discharge. The primary outcome will be the proportion of prescribed opioids consumed by patients at 7 days postdischarge. Secondary outcomes will include patient-reported quality of life and satisfaction scores, rate of non-opioid analgesic use, rate of continuing use of opioids at follow-up, rates of opioid prescription from other sources and hospital readmissions at 7 days postdischarge for opioid related side-effects or surgery-related pain. Descriptive and multivariate analyses will be conducted to investigate factors associated with opioid requirements and prescription-consumption discrepancies.

ETHICS AND DISSEMINATION

OPERAS has been approved in Australia by the Hunter New England Human Research Ethics Committee (Protocol 2021/ETH11508) and by the Southern Health and Disability Ethics Committee (2021 EXP 11199) in Aotearoa New Zealand. Results will be submitted for conference presentation and peer-reviewed publication. Centre-level data will be distributed to participating sites for internal audit.

TRIAL REGISTRATION NUMBER

ANZCTR (ID: ACTRN12621001451897p).

Intraperitoneal drain placement and outcomes after elective colorectal surgery: international matched, prospective, cohort study

BACKGROUND

Many surgeons routinely place intraperitoneal drains after elective colorectal surgery. However, enhanced recovery after surgery guidelines recommend against their routine use owing to a lack of clear clinical benefit. This study aimed to describe international variation in intraperitoneal drain placement and the safety of this practice.

METHODS

COMPASS (COMPlicAted intra-abdominal collectionS after colorectal Surgery) was a prospective, international, cohort study which enrolled consecutive adults undergoing elective colorectal surgery (February to March 2020). The primary outcome was the rate of intraperitoneal drain placement. Secondary outcomes included: rate and time to diagnosis of postoperative intraperitoneal collections; rate of surgical site infections (SSIs); time to discharge; and 30-day major postoperative complications (Clavien-Dindo grade at least III). After propensity score matching, multivariable logistic regression and Cox proportional hazards regression were used to estimate the independent association of the secondary outcomes with drain placement.

RESULTS

Overall, 1805 patients from 22 countries were included (798 women, 44.2 per cent; median age 67.0 years). The drain insertion rate was 51.9 per cent (937 patients). After matching, drains were not associated with reduced rates (odds ratio (OR) 1.33, 95 per cent c.i. 0.79 to 2.23; P = 0.287) or earlier detection (hazard ratio (HR) 0.87, 0.33 to 2.31; P = 0.780) of collections. Although not associated with worse major postoperative complications (OR 1.09, 0.68 to 1.75; P = 0.709), drains were associated with delayed hospital discharge (HR 0.58, 0.52 to 0.66; P < 0.001) and an increased risk of SSIs (OR 2.47, 1.50 to 4.05; P < 0.001).

CONCLUSION

Intraperitoneal drain placement after elective colorectal surgery is not associated with earlier detection of postoperative collections, but prolongs hospital stay and increases SSI risk.

Impact of routine nasogastric decompression versus no nasogastric decompression after pancreaticoduodenectomy on perioperative outcomes: meta-analysis

Background

Consensus on the use of nasogastric decompression (NGD) after pancreaticoduodenectomy (PD) is lacking. This meta-analysis reviewed current evidence on the impact of routine NGD versus no NGD after PD on perioperative outcomes.

Methods

PubMed, Medline, Scopus, Embase and Cochrane databases were searched for studies reporting on the role of NGD after PD on perioperative outcomes. Data up to January 2021were retrieved and analysed.

Results

Eight studies were included, with a total of 1301 patients enrolled, of whom 668 had routine NGD. Routine NGD was associated with a higher incidence of overall delayed gastric emptying (DGE) (odds ratio (OR) 2.51, 95 per cent c.i. 1.12 to 5.63, I² = 83 per cent; P = 0.03) and clinically relevant DGE (OR 3.64, 95 per cent c.i. 1.83 to 7.25, I² = 54 per cent; P < 0.01), a higher rate of Clavien–Dindo grade II or higher complications (OR 3.12, 95 per cent c.i. 1.05 to 9.28, I² = 88 per cent; P = 0.04) and increased length of hospital stay (mean difference 2.67, 95 per cent c.i. 0.60 to 4.75, I² = 97 per cent; P = 0.02). There were no significant differences in overall complications (OR 1.07, 95 per cent c.i. 0.79 to 1.46, I² = 0 per cent; P = 0.66) or postoperative pancreatic fistula (OR 1.21, 95 per cent c.i. 0.86 to 1.72, I² = 0 per cent; P = 0.28) between patients with or those without routine NGD.

Conclusion

Routine NGD was associated with increased rates of DGE, major complications and longer length of stay after PD.

Collaboration in colorectal surgical research

Surgical research has been under-powered, under-funded and under-delivered for decades. A solution may be to form large research collaborations and thereby enable implementation of successful interventional trials as well as robust international observational studies with thousands of patients. There are many such research collaborations in colorectal surgery, and in this paper we have highlighted the experiences from the West Midlands Research Collaborative (WMRC), the Scandinavian Surgical Outcomes Research Group (SSORG) and the European Society of Coloproctology. With active research networks, it is possible to deliver large, high-quality studies and provide high-level evidence for solving important clinical questions in an efficient and timely manner.