Accuracy of the Wound Healing Questionnaire in the diagnosis of surgical-site infection after abdominal surgery in low- and middle-income countries

INTRODUCTION

Telemedicine is being adopted for postoperative surveillance but requires evaluation for efficacy. This study tested a telephone Wound Healing Questionnaire (WHQ) to diagnose surgical site infection (SSI) after abdominal surgery in low- and middle-income countries.

METHOD

A multi-centre, international, prospective study was embedded in the FALCON trial; a factorial RCT testing measures to reduce SSI in seven low- and middle-income countries (NCT03700749). It was conducted according to a pre-registered protocol (SWAT126) and reported according to STARD guidelines. The reference test was in-person review by a trained clinician at 30 postoperative days according to US Centres for Disease Control criteria. The index test was telephone administration of an adapted WHQ at 27 to 30 postoperative days by a researcher blinded to the outcome of in-person review. The sum of item response scores generated an overall score between 0 and 29. The primary outcome was the diagnostic accuracy of the WHQ, defined as the proportion of SSI correctly identified by the telephone WHQ, and summarized using the area under the receiving operator characteristic curve (AUROC) and diagnostic test accuracy statistics.

RESULTS

Patients were included from three upper-middle income (396 patients, 13 hospitals), three lower-middle income (746 patients, 19 hospitals), and one low-income country (54 patients, 4 hospitals). 90.3% (1088 of 1196) patients were successfully contacted. Those with non-midline incisions (adjusted odds ratio: 0.36, 95% c.i. 0.17 to 0.73, P=0.005) or a confirmed diagnosis of SSI on in-person assessment (odds ratio: 0.42, 95% c.i. 0.20 to 0.92, P=0.006) were harder to reach. The questionnaire correctly discriminated between most patients with and without SSI (AUROC 0.869, 95% c.i. 0.824 to 0.914), which was consistent across subgroups. A representative cut-off score of ≥4 displayed a sensitivity of 0.701 (0.610-0.792), specificity of 0.911 (0.878-0.943), positive predictive value of 0.723 (0.633-0.814) and negative predictive value of 0.901 (0.867-0.935).

CONCLUSION

SSI can be diagnosed using a telephone questionnaire (obviating in-person assessment) in low resource settings.

Breast Cancer Stage at Diagnosis in a Nigerian Hospital: Trend over a Decade

BACKGROUND

Breast cancer outcomes are poor in Nigeria, partly due to late-stage diagnosis. To assess the impact of past and present interventions, a review of an institutional data base was performed to determine the trend with respect to stage at diagnosis over a decade.

METHODS

A retrospective analysis of an institutional data base was performed over a decade. The review period was divided into segments (2013-2015, 2016-2018 and 2019-2022). The latter period (2019-2022), corresponds to a time of more intense community interventions aimed at promoting early diagnosis and treatment around the locality of the teaching hospital. The stage at diagnosis within these periods were compared. The relationship between stage and sociodemographic variables (age, religion, marital status, menopausal status, and level of education) was assessed.

RESULTS

There were 910 patients, 144 within the first period (2013-2015), 318 in the second (2016-2018) and 454 in the third period (2019-2022). The majority presented with stage 3 disease (73.8%). There was a significant decline in the proportion of metastatic cases and a concomitant increase in early cases in the latter part of the review. The proportion of metastatic cases reduced from 23.6% (2013-2015), to 15.7% (2016-2018) and 9.3% (2019-2022) (p=0.001). Level of education was significantly associated with stage (p=0.001).

CONCLUSION

This study shows a trend towards downstaging of breast cancer in our locality. This trend corresponds to the period of more intense community interventions, justifying the need to further interrogate the direct impact of each of the interventions. This will provide a firm basis for sustaining or improving on current efforts to achieve more robust gains.

A Prospective, Observational Cost Comparison of Laparoscopic and Open Appendicectomy in Three Tertiary Hospitals in Nigeria

BACKGROUND

The clinical benefits of laparoscopic appendicectomy are well recognized over open appendicectomy. However, laparoscopic procedures are not frequently conducted in many low-and middle-income countries (LMICs) for several reasons, including perceived higher costs. The aim of this study was to assess the feasibility and cost of laparoscopic appendicectomy compared to open appendicectomy in Nigeria.

METHODS

A multicenter, prospective, cohort study among patients undergoing appendicectomy was conducted at three tertiary hospitals in Nigeria. Data were collected from October 2020 to February 2022 and analyses compared the average healthcare costs at 30 days after surgery. Quantile regression was conducted to identify variables that had an impact on the costs, reported in Nigerian Naira (Naira) and US dollars ($), with standard deviations (SD).

FINDINGS

This study included 105 patients, of which 39 had laparoscopic appendicectomy and 66 had open appendicectomy. The average healthcare cost of laparoscopic appendicectomy (147,562 Naira (SD: 97,130) or $355 (SD: 234)) was higher than open appendicectomy (113,556 Naira (SD: 88,559) or $273 (SD: 213)). The average time for return to work was shorter with laparoscopic than open appendicectomy (mean: 8 days vs. 14 days). At the average daily income of $5.06, laparoscopic appendicectomy was associated with 9778 Naira or $24 cost savings in return to work. Further, 5.1% of laparoscopic appendicectomy patients had surgical site infections compared to 22.7% for open appendicectomy. Regression analysis results showed that laparoscopic appendicectomy was associated with $14 higher costs than open appendicectomy, albeit non-significant (p = 0.53).

INTERPRETATION

Despite selection bias in this real-world study, laparoscopic appendicectomy was associated with a slightly higher overall cost, a lower societal cost, a lower infection rate, and a faster return to work, compared to open appendicectomy. It is technically and financially feasible, and its provision in Nigeria should be expanded.

Immediate lymph node extraction improves retrieval rate following axillary lymph node dissection: an effective approach to improving guideline-concordant breast cancer care in Nigeria

Background

Axillary lymph node staging is essential for making therapeutic decisions and for prognostication. A minimum of ten lymph nodes is recommended for accurate staging. This study describes the process and outcomes of an audit cycle that resulted in a novel intervention instituted to improve concordance with guidelines.

Methods

The study began with a retrospective audit of lymph node retrieval following axillary lymph node dissection (ALND). Subsequent phases evaluated the efficacy of immediate lymph node extraction before fixation by comparing the mean number of lymph nodes and the proportion of guideline-concordant cases to retrospective data and concurrent cases without the intervention.

Results

The mean number of lymph nodes retrieved in the retrospective phase was 5.2, which is less than the recommended threshold. The intervention resulted in a significant increase in lymph node retrieval over the baseline rate (13.7 versus 5.2, p = 0.026). There was also a significantly higher number of lymph nodes following the intervention compared to concurrent cases managed during the same period without the intervention (13.7 versus 7.9, p = 0.004). The concordance rate was 89% in the intervention group compared to 47% in the non-intervention group (p = 0.019). There was no significant difference when the intervention was administered by either surgeons or pathologists (13.5 versus 12, p = 0.25).

Conclusion

Immediate extraction of lymph nodes resulted in significant improvement of concordant lymph node retrieval in all phases of the study. We recommend that this practice be validated in larger cohorts for possible recommendation as an effective way of improving lymph node retrieval following ALND.

Prevalence and determinants of lymphedema in newly diagnosed Nigerian breast cancer patients using bioimpedance estimations

Background

Breast cancer-related lymphedema (BCRL) is common and has significant impact on quality of life. Very little is known about BCRL in sub-Saharan Africa. Generally, BCRL has been mostly evaluated post treatment, with very limited data on the prevalence of pre-treatment BCRL at baseline. This study presents the prevalence and clinical associations of lymphedema among newly diagnosed, treatment-naive breast cancer patients in a Nigerian cohort using bioimpedance estimations.

Methods

Consecutively consenting, newly diagnosed, treatment-naive breast cancer patients were assessed for upper limb lymphedema using bioimpedance measurements of the extracellular fluid and the single-frequency bioelectrical impedance analysis value at 5 kHz. Patients were classified as having lymphedema if there was >10% difference in arm measurements or if the ratios of the arm measurements were >3 SD above a normative mean generated from representative controls. Regression analysis was performed to determine clinical variables associated with lymphedema.

Results

There were 154 breast cancer patients with a median age of 47 (40.0-56.8) years and a body mass index of 27 (23.5-30.9) kg/m². The majority (70%) had stage III disease. All measurements were significantly higher in cases than controls. Using various definitions, the prevalence of lymphedema was between 11.7% and 14.3%. Various clinical variables relating to clinical stage were significantly associated with lymphedema.

Conclusion

The predominance of locally advanced disease in the Nigerian setting is associated with high pre-treatment lymphedema rates. This may set the stage for higher rates in the post-operative setting. Management of lymphedema should be incorporated into the treatment planning.

An Outcomes-Focused Analysis of Laparoscopic and Open Surgery in a Nigerian Hospital

Background/Objectives

The benefits of laparoscopic surgery such as swifter recovery and fewer wound complications, elude much of the developing world. Nigeria, a lower middle-income country, is the most populous sub-Saharan nation; an excellent model for studying the impact of laparoscopy in resource-constrained environments. The Department of Surgery at the Obafemi Awolowo University Teaching Hospital and the University of Utah's Center for Global Surgery present a study of laparoscopic surgery cases in sub-Saharan Africa.

Methods

A retrospective chart review of 261 patients compared open and laparoscopic surgical outcomes for three common general surgery procedures: open versus laparoscopic cholecystectomy and appendectomy, and open laparotomy versus diagnostic laparoscopy for biopsy of intra-abdominal mass. The primary outcome was total length of stay (LOS); secondary outcomes included wound complications, analgesia and antibiotic use, time to oral intake, and patient charges.

Results

Total LOS for laparoscopic surgery was significantly shorter compared to analogous open procedures (4.7 vs 11.5 days). Postoperative LOS was also shorter (2.6 vs 8.2 days). There were no differences in wound complications. Median charges to patients were lower for laparoscopic versus open procedures ($184 vs $217 USD).

Conclusions

The introduction of laparoscopy allows for significantly shorter LOS and equivalent wound complications in the context of a sub-Saharan teaching hospital. Concerns regarding higher costs of care for patients do not appear to be a significant issue. Further work is needed to evaluate costs to the hospital system as a whole, including procurement and maintenance of laparoscopic equipment.

Effectiveness of Triclosan Coated Suture for Subcutaneous Wound Closure in Preventing Surgical Site Infection following Mesh Repair of Inguinal Hernia: A Pilot Study

BACKGROUND

The role of prophylactic antibiotics in mesh repair of inguinal hernia is controversial and often based on institutional policies. Surgical site infection rate from earlier studies in Nigeria justifies the continued use of prophylactic antibiotics during hernia repair. With increased use of antibiotics comes the challenge of antibiotic resistance and toxicity. The use of antimicrobial coated suture may help avoid these challenges but its efficacy needs to be tested.

OBJECTIVE

To compare Triclosan coated suture with intravenous antibiotics for the repair of inguinal hernia with mesh.

METHODS

Patients with uncomplicated inguinal hernia undergoing mesh repair were randomized to either have intravenous antibiotics administered for prophylaxis or to have wound closure with Triclosan coated Vicryl 2/0 suture. Post operatively, wound infection rates were compared between the two groups. Follow up was for 1 year.

RESULTS

We studied 49 patients with 59 hernias with a mean age of 53 years. Hernias were solitary in 75% of cases, the majority of which were right sided, while 25% were bilateral. There were 25 patients with 32 hernias in the Intravenous antibiotic group (Group A) and 24 patients with 27 hernias in the Triclosan suture group (Group B). Wound grades were similar between the two groups with one patient in the Triclosan group confirmed to have wound infection (4.2%) and none in the Intravenous antibiotics group (p=0.27). Wound infection was of the superficial type which resolved with wound care within 1 month.

CONCLUSION

Triclosan coated suture may be safely used as an alternative to intravenous antibiotics for the mesh repair of inguinal hernia. Further studies are required to validate this finding.

Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

BACKGROUND

80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality.

METHODS

This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494.

FINDINGS

Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70-8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39-8·80) and upper-middle-income countries (2·06, 1·11-3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26-11·59) and upper-middle-income countries (3·89, 2·08-7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications.

INTERPRETATION

Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications.

FUNDING

National Institute for Health Research Global Health Research Unit.

Intrathoracic Complications of Amoebic Liver Abscess

Amoebiasis is a world-wide parasitic infestation but is more prevalent and virulent in warm countries. Of 33 patients with amoebic liver abscess (ALA) seen over a 5-year period, 24 had intrathoracic complications. Management consisted mainly of the administration of the antiamoebic agent metronidazole (Flagyl), repeated needle aspiration of ALA and surgical drainage when aspiration failed. Closed tube thoracostomy was the preferred management of amoebic empyema. Associated cerebral involvement in 4 cases improved with parenteral metronidazole. Pericardial amoebic abscess claimed 100% mortality in our series.