Management and Outcomes Following Surgery for Gastrointestinal Typhoid: An International, Prospective, Multicentre Cohort Study

Typhoid Intestinal Perforation Prognostic Score in Poor-Resource Settings

Background

Mortality from peritonitis due to typhoid intestinal perforation (TIP) in sub-Saharan Africa is high.

Objectives

This study aimed to determine the predictive factors of mortality, propose a prognostic score, and determine the appropriate surgical treatment for TIP in low-resource settings.

Materials and Methods

This was a retrospective data collection of peritonitis due to TIP admitted at Zinder National Hospital from 2014 to 2021. To build a typhoid intestinal perforation prognostic score (TIPPS), patients were randomised into two groups: a score-building group and a validation group. Univariate and multivariate analyses were performed to identify risk factors of mortality. The value of P <0.05 was assigned significant for all analyses.

Results

TIP accounted for 52.4% (n = 1132) of all cases of peritonitis (n = 2159). The median age was 12 years. Rural provenance represented 72.2% (n = 817). Deaths accounted for 10.5% (n = 119). The factors influencing mortality were respiratory rate ≥24/min (odds ratio [OR] = 2.6, P = 0.000), systolic blood pressure <90 mmHg (OR = 0.31, P = 0.002), serum creatinine >20 mg/L (OR = 2.6, P ≤ 0.009), haemoglobin (OR = 2.1, P = 0.000), comorbidity (OR = 3.5, P = 0.001), the American Society of Anesthesiologists score IV&V (OR = 3.3, P = 0.000), admission and management delay > 72 h (OR = 3.2, P = 0.001), and a number of perforations (OR = 2.4, P = 0.0001). These factors were used to build a "TIPPS" score, which ranged from 8 to 20. The risk of mortality was associated with increased TIPPS. The performance of this score was good in the two groups (area under receiver operating characteristic > 0.83). According to the severity and mortality risk of TIP, we classified TIPS into four grades: grade I (low risk: 8-10), grade II (moderate risk: 11-13), grade III (high risk: 14-16) and grade IV (very high risk: 17-20).

Conclusion

The TIPPS is simple. It can describe the severity of the disease and can predict the risk of death. The study highlights the importance and impact of timely and adequate perioperative resuscitation in more complicated cases.

Characterization of Typhoid Intestinal Perforation in Africa: Results From the Severe Typhoid Fever Surveillance in Africa Program

Background

Typhoid intestinal perforation (TIP) remains the most serious complication of typhoid fever. In many countries, the diagnosis of TIP relies on intraoperative identification, as blood culture and pathology capacity remain limited. As a result, many cases of TIP may not be reported as typhoid. This study demonstrates the burden of TIP in sites in Burkina Faso, Democratic Republic of Congo (DRC), Ethiopia, Ghana, Madagascar, and Nigeria.

Methods

Patients with clinical suspicion of nontraumatic intestinal perforation were enrolled and demographic details, clinical findings, surgical records, blood cultures, tissue biopsies, and peritoneal fluid were collected. Participants were then classified as having confirmed TIP, probable TIP, possible TIP, or clinical intestinal perforation based on surgical descriptions and cultures.

Results

A total of 608 participants were investigated for nontraumatic intestinal perforation; 214 (35%) participants had surgically-confirmed TIP and 33 participants (5%) had culture-confirmed typhoid. The overall proportion of blood or surgical site Salmonella enterica subspecies enterica serovar Typhi positivity in surgically verified TIP cases was 10.3%. TIP was high in children aged 5-14 years in DRC, Ghana, and Nigeria. We provide evidence for correlation between monthly case counts of S. Typhi and the occurrence of intestinal perforation.

Conclusions

Low S. Typhi culture positivity rates, as well as a lack of blood and tissue culture capability in many regions where typhoid remains endemic, significantly underestimate the true burden of typhoid fever. The occurrence of TIP may indicate underlying typhoid burden, particularly in countries with limited culture capability.

Improving Surgical Research Capacity in Low- and Middle-Income Countries: Can Episodic Data Collection Reliably Estimate Perioperative Mortality?

OBJECTIVE

The aim of this study was to empirically determine the optimal sample size needed to reliably estimate perioperative mortality (POMR) in different contexts.

SUMMARY BACKGROUND DATA

POMR is a key metric for measuring the quality and safety of surgical systems and will need to be tracked as surgical care is scaled up globally. Continuous collection of outcomes for all surgical cases is not the standard in high-income countries and may not be necessary in low- and middle-income countries.

METHODS

We created simulated datasets to determine the sampling frame needed to reach a given precision. We validated our findings using data collected at Mulago National Referral Hospital in Kampala, Uganda. We used these data to create a tool that can be used to determine the optimal sampling frame for a population based on POMR rate and target POMR improvement goal.

RESULTS

Precision improved as the sampling frame increased. However, as POMR increased, lower sampling percentages were needed to achieve a given precision. A total of 357 eligible cases were identified in the Mulago database with an overall POMR rate of 14%. Precision of ±10% was achieved with 34% sampling, and precision of ±25% was obtained at 9% sampling. Using simulated datasets, a tool was created to determine the minimum sample percentage needed to detect a given mortality improvement goal.

CONCLUSIONS

Reliably tracking POMR does not require continuous data collection. Data driven sampling strategies can be used to decrease the burden of data collection to track POMR in resource-constrained settings.

Paediatric surgical outcomes in sub-Saharan Africa: a multicentre, international, prospective cohort study

INTRODUCTION

As childhood mortality from infectious diseases falls across sub-Saharan Africa (SSA), the burden of disease attributed to surgical conditions is increasing. However, limited data exist on paediatric surgical outcomes in SSA. We compared the outcomes of five common paediatric surgical conditions in SSA with published benchmark data from high-income countries (HICs).

METHODS

A multicentre, international, prospective cohort study was undertaken in hospitals providing paediatric surgical care across SSA. Data were collected on consecutive children (birth to 16 years), presenting with gastroschisis, anorectal malformation, intussusception, appendicitis or inguinal hernia, over a minimum of 1 month, between October 2016 and April 2017. Participating hospitals completed a survey on their resources available for paediatric surgery.The primary outcome was all-cause in-hospital mortality. Mortality in SSA was compared with published benchmark mortality in HICs using χ² analysis. Generalised linear mixed models were used to identify patient-level and hospital-level factors affecting mortality. A p<0.05 was deemed significant.

RESULTS

1407 children from 51 hospitals in 19 countries across SSA were studied: 111 with gastroschisis, 188 anorectal malformation, 225 intussusception, 250 appendicitis and 633 inguinal hernia. Mortality was significantly higher in SSA compared with HICs for all conditions: gastroschisis (75.5% vs 2.0%), anorectal malformation (11.2% vs 2.9%), intussusception (9.4% vs 0.2%), appendicitis (0.4% vs 0.0%) and inguinal hernia (0.2% vs 0.0%), respectively. Mortality was 41.9% (112/267) among neonates, 5.0% (20/403) in infants and 1.0% (7/720) in children. Paediatric surgical condition, higher American Society of Anesthesiologists score at primary intervention, and needing/receiving a blood transfusion were significantly associated with mortality on multivariable analysis.

CONCLUSION

Mortality from common paediatric surgical conditions is unacceptably high in SSA compared with HICs, particularly for neonates. Interventions to reduce mortality should focus on improving resuscitation and timely transfer at the district level, and preoperative resuscitation and perioperative care at paediatric surgical centres.

Complications and mortality of typhoid fever: A global systematic review and meta-analysis

•

Complications and death are considerable among hospitalized patients with typhoid fever.

•

Case fatality ratio of typhoid fever was higher in Africa compared to Asia.

•

Among studies in Africa, 20% of patients with typhoid intestinal perforation died.

•

Delays in care were correlated with increased typhoid case fatality ratio in Asia.

Objectives

Updated estimates of the prevalence of complications and case fatality ratio (CFR) among typhoid fever patients are needed to understand disease burden.

Methods

Articles published in PubMed and Web of Science from 1 January 1980 through 29 January 2020 were systematically reviewed for hospital or community-based non-surgical studies that used cultures of normally sterile sites, and hospital surgical studies of typhoid intestinal perforation (TIP) with intra- or post-operative findings suggestive of typhoid. Prevalence of 21 pre-selected recognized complications of typhoid fever, crude and median (interquartile range) CFR, and pooled CFR estimates using a random effects meta-analysis were calculated.

Results

Of 113 study sites, 106 (93.8%) were located in Asia and Africa, and 84 (74.3%) were non-surgical. Among non-surgical studies, 70 (83.3%) were hospital-based. Of 10,355 confirmed typhoid patients, 2,719 (26.3%) had complications. The pooled CFR estimate among non-surgical patients was 0.9% for the Asia region and 5.4% for the Africa region. Delay in care was significantly correlated with increased CFR in Asia (r = 0.84; p<0.01). Among surgical studies, the median CFR of TIP was 15.5% (6.7–24.1%) per study.

Conclusions

Our findings identify considerable typhoid-associated illness and death that could be averted with prevention measures, including typhoid conjugate vaccine introduction.

Morbidity and Mortality of Typhoid Intestinal Perforation Among Children in Sub-Saharan Africa 1995-2019: A Scoping Review

BACKGROUND

Typhoid fever incidence and complications, including intestinal perforation, have declined significantly in high-income countries, with mortality rates <1%. However, an estimated 10.9 million cases still occur annually, most in low- and middle-income countries. With the availability of a new typhoid conjugate vaccine licensed for children and recommended by the World Health Organization, understanding severe complications, including associated mortality rates, is essential to inform country-level decisions on introduction of this vaccine. This scoping review summarizes over 20 years of the literature on typhoid intestinal perforation in sub-Saharan Africa.

METHODS

We searched EMBASE, PubMed, Medline, and Cochrane databases for studies reporting mortality rates due to typhoid intestinal perforation in children, under 18 years old, in sub-Saharan Africa published from January 1995 through June 2019.

RESULTS

Twenty-four papers from six countries were included. Reported mortality rates ranged from 4.6-75%, with 16 of the 24 studies between 11 and 30%. Thirteen papers included postoperative morbidity rates, ranging from 16-100%. The most documented complications included surgical site infections, intra-abdominal abscesses, and enterocutaneous fistulas. High mortality rates can be attributed to late presentation to tertiary centers, sepsis and electrolyte abnormalities requiring preoperative resuscitation, prolonged perforation-to-surgery interval, and lack of access to critical care or an intensive care unit postoperatively.

CONCLUSIONS

Current estimates of mortality related to typhoid intestinal perforation among children in sub-Saharan Africa remain unacceptably high. Prevention of typhoid fever is essential to reduce mortality, with the ultimate goal of a comprehensive approach that utilizes vaccination, improvements in water, sanitation, and hygiene, and greater access to surgical care.

Perioperative mortality as a meaningful indicator: Challenges and solutions for measurement, interpretation, and health system improvement

Expanding global access to safe surgical and anaesthesia care is crucial to meet the health targets of the Sustainable Development Goals (SDGs). As global surgical volume increases, improving safety throughout the patient care pathway is a public health priority. At present, an estimated 4.2 million individuals die within 30 days of surgery each year, and many of these deaths are preventable. Important considerations for the collection and reporting of perioperative mortality data have been identified in the literature, but consensus has not been established on the best methodology for the quantification of excess surgical mortality at a hospital or health system level. In this narrative review, we address challenges in the use of perioperative mortality rates (POMR) for improving patient safety. First, we discuss controversies in the use of POMR as a health system indicator and suggest advantages for using a "basket" of procedure-specific mortality rates as an adjunct to gross POMR. We offer then solutions to challenges in the collection and reporting of POMR data, and propose interventions for improving care in the preoperative, operative, and postoperative periods. Finally, we discuss how health systems leaders and frontline clinicians can integrate surgical safety into both national health plans and patient care pathways to drive a sustainable safety revolution in perioperative care.

Management of intra-abdominal-infections: 2017 World Society of Emergency Surgery guidelines summary focused on remote areas and low-income nations

BACKGROUND

Most remote areas have restricted access to healthcare services and are too small and remote to sustain specialist services. In 2017, the World Society of Emergency Surgery (WSES) published guidelines for the management of intra-abdominal infections. Many hospitals, especially those in remote areas, continue to face logistical barriers, leading to an overall poorer adherence to international guidelines.

METHODS

The aim of this paper is to report and amend the 2017 WSES guidelines for the management of intra-abdominal infections, extending these recommendations for remote areas and low-income countries. A literature search of the PubMed/MEDLINE databases was conducted covering the period up until June 2020.

RESULTS

The critical shortages of healthcare workers and material resources in remote areas require the use of a robust triage system. A combination of abdominal signs and symptoms with early warning signs may be used to screen patients needing immediate acute care surgery. A tailored diagnostic step-up approach based on the hospital's resources is recommended. Ultrasound and plain X-ray may be useful diagnostic tools in remote areas. The source of infection should be totally controlled as soon as possible.

CONCLUSIONS

The cornerstones of effective treatment for intra-abdominal infections in remote areas include early diagnosis, prompt resuscitation, early source control, and appropriate antimicrobial therapy. Standardization in applying the guidelines is mandatory to adequately manage intra-abdominal infections.

What is 'global surgery'? Defining the multidisciplinary interface between surgery, anaesthesia and public health

'Global surgery' is the term adopted to describe a rapidly developing multidisciplinary field aiming to provide improved and equitable surgical care across international health systems. Sitting at the interface between numerous clinical and non-clinical specialisms, it encompasses multiple aspects that surround the treatment of surgical disease and its equitable provision across health systems globally. From defining the role of, and need for, optimal surgical care through to identifying barriers and implementing improvement, global surgery has an expansive remit. Advocacy, education, research and clinical components can all involve surgeons, anaesthetists, nurses and allied healthcare professionals working together with non-clinicians, including policy makers, epidemiologists and economists. Long neglected as a topic within the global and public health arenas, an increasing awareness of the extreme disparities internationally has driven greater engagement. Not necessarily restricted to specific diseases, populations or geographical regions, these disparities have led to a particular focus on surgical care in low-income and middle-income countries with the greatest burden and needs. This review considers the major factors defining the interface between surgery, anaesthesia and public health in these settings.

Global children's surgery: recent advances and future directions

PURPOSE OF REVIEW

Two-thirds of the world's population lacks access to surgical care, many of them being children. This review provides an update on recent advances in global children's surgery.

RECENT FINDINGS

Surgery is being increasingly recognized as an essential component of global and child health. There is a greater focus on sustainable collaborations between high-income countries (HICs) and low-and-middle-income countries (HICs and LMICs). Recent work provides greater insight into the global disease burden, perioperative outcomes and effective context-specific solutions. Surgery has continued to be identified as a cost-effective intervention in LMICs. There have also been substantial advances in research and advocacy for a number of childhood surgical conditions.

SUMMARY

Substantial global disparities persist in the care of childhood surgical conditions. Recent work has provided greater visibility to the challenges and solutions for children's surgery in LMICs. Capacity-building and scale up of children's surgical care, more robust implementation research and ongoing advocacy are needed to increase access to children's surgical care worldwide.