Outcome assessment of emergency laparotomies and associated factors in low resource setting. A case series

Magnitude of in-hospital mortality and its associated factors among patients undergone laparotomy at tertiary public hospitals, West Oromia, Ethiopia, 2022

INTRODUCTION

Laparotomy surgery, which involves making an incision in the abdominal cavity to treat serious abdominal disease and save the patient's life, causes significant deaths in both developed and developing countries, including Ethiopia. The number studies examining in-hospital mortality rates among individuals that undergone laparotomy surgery and associated risk factors is limited.

OBJECTIVE

To assess the magnitude of in-hospital mortality and its associated factors among patients undergone laparotomy at tertiary hospitals, West Oromia, Ethiopia, 2022.

METHODS

An institutional based retrospective cross-sectional study was conducted from January 1, 2017, to December 31, 2021. Data were collected using systematic random sampling and based on structured and pretested abstraction sheets from 548 medical records and patient register log. Data were checked for completeness and consistency, coded, imported using Epi-data version 4.6, cleaned and analyzed using SPSS version 25 software. Variables with p < 0.2 in the Bi-variable logistic regression analysis were included in the multivariate logistic regression analysis. The fit of the model was checked by the Hosmer‒Lemeshow test. Using the odds ratio adjusted to 95% CI and a p value of 0.05, statistical significance was declared.

RESULTS

A total of 512 patient charts were reviewed, and the response rate was 93.43%. The overall magnitude of in-hospital mortality was 7.42% [95% CI: 5.4-9.8]. American society of Anesthesiology physiological status greater than III [AOR = 7.64 (95% CI: 3.12-18.66)], systolic blood pressure less than 90 mmHg [AOR = 6.11 (95% CI: 1.98-18.80)], preoperative sepsis [AOR = 3.54 (95% CI: 1.53-8.19)], ICU admission [AOR = 4.75 (95% CI: 1.50-14.96)], and total hospital stay greater than 14 days [(AOR = 6.76 (95% CI: 2.50-18.26)] were significantly associated with mortality after laparotomy surgery.

CONCUSSION

In this study, overall in- hospital mortality was high. Early identification patient's American Society of Anesthesiologists physiological status and provision of early appropriate intervention, and pays special attention to patients admitted with low systolic blood pressure, preoperative sepsis, intensive care unit admission and prolonged hospital stay to improve patient outcomes after laparotomy surgery.

Magnitude and associated factors of postoperative mortality among patients who underwent surgery in Ethiopia: systematic review and meta-analysis

Background

Postoperative mortality is one of the six surgical indicators identified by the Lancet Commission on Global Surgery for monitoring access to high-quality surgical care. This study aimed to assess the magnitude and associated factors of postoperative mortality among patients who underwent surgery in Ethiopia.

Methods

This systematic review and meta-analysis were conducted based on the Preferred Reporting Items for Systematic Review and Meta-analysis guidelines. Ten studies were included in this Systematic review and meta-analysis. The risk of bias for each study was assessed using the Joanna Briggs Institute quality appraisal scale. Publication bias was checked using a funnel plot and Egger's regression test. Heterogeneity across studies was assessed by I2 statistics. STATA version 17 software was used for analysis. A random effect model and the DerSimonian-Laird method of estimation was used to estimate the pooled magnitude of postoperative mortality. Odds ratios with 95% CIs were calculated to determine the associations of the identified factors with postoperative mortality.

Results

The results revealed that the pooled magnitude of postoperative mortality among patients who underwent surgery in Ethiopia was 4.53% (95% CI :3.70-5.37). An American Society of Anesthesiologists score greater than or equal to III [adjusted odds ratio (AOR): 2.45, 95% CI: 2.02, 2.96], age older than or equal to 65 years (AOR: 3.03, 95% CI: 2.78, 3.31), and comorbidity (AOR: 3.28, 95% CI: 1.91, 5.63) were significantly associated with postoperative mortality.

Conclusion and recommendations

The pooled magnitude of postoperative mortality among patients who underwent surgery in Ethiopia was high. The presence of comorbidities, age older than 65 years, and ASA physical status greater than III were significantly associated with postoperative mortality. Therefore, the Ministry of Health and other concerned bodies should consider quality improvement processes.

Comparison of surgical site infection (SSI) between negative pressure wound therapy (NPWT) assisted delayed primary closure and conventional delayed primary closure in grossly contaminated emergency abdominal surgeries: a randomized controlled trial

PURPOSE

NPWT has been tried in many surgical fields, including colorectal, thoracic, vascular, and non-healing wounds, for the prevention of SSI. However, its efficacy in the prevention of SSI-grade IV closed abdominal wounds is yet to be explored.

METHODS

All patients with grade IV abdominal wounds were included in the study. They were randomized into the conventional arm and the VAC arm after confirming the diagnosis intra-operatively. The sheath was closed, and the skin was laid open in the postoperative period. In the VAC arm, the NPWT dressing was applied on postoperative day (POD)-1 and removed on POD-5. In the conventional arm, only regular dressing was done postoperatively. The skin was closed with a delayed primary intention on POD-5 in both arms. The sutures were removed after 7 to 10 days of skin closure.

RESULTS

The rate of SSI (10% in the VAC arm vs. 37.5% in the conventional arm, p-value = 0.004) was significantly lower in the VAC arm, as were the rates of seroma formation (2.4% in the VAC arm vs. 20% in the conventional arm, p = 0.014) and wound dehiscence (7.3% vs. 30%, p = 0.011). The conventional arm had a significant delay in skin closure beyond POD5 due to an increased rate of SSI, which also led to a prolonged hospital stay (5 days in the VAC arm vs. 6.5 days in the conventional arm, p-value = 0.005).

CONCLUSION

The VAC dressing can be used routinely in grade IV closed abdominal wounds to reduce the risk of SSI and wound dehiscence.

Quantifying the impact of reduced opioid use in patients after emergency laparotomy

BACKGROUND

Emergency laparotomies have high rates of morbidity and mortality. The evaluation and management of pain are crucial, as poorly managed pain may contribute to postoperative complications and increase the risk of mortality. This study aims to describe the relationship between opioid use and opioid-related adverse effects and identify what constitutes appropriate dose reductions to elicit clinically relevant benefits.

METHODS

This was a retrospective, observational study of patients presenting for emergency laparotomy due to trauma from 2014 to 2018. The primary objective was to define clinical outcomes that may be significantly affected by changes in milligrams of morphine equivalent during the first 72 hours postoperatively; additionally, we sought to quantify the approximate differences in morphine equivalent that correlate with clinically meaningful outcomes such as hospital length of stay, pain scores, and time to first bowel movement. For descriptive summaries, patients were categorized into low, moderate, and high groups based on morphine equivalent requirements of 0 to 25, 25 to 50, and >50, respectively.

RESULTS

A total of 102 (35%), 84 (29%), and 105 (36%) patients were stratified into the low, moderate, and high groups, respectively. Mean pain scores for postoperative days 0 to 3 (P = .034), time to first bowel movement (P = .002), and nasogastric tube duration (P = .003) were the clinical outcomes found to be significantly associated with morphine equivalent. Estimated clinically significant reductions in morphine equivalent for these outcomes ranged from 194 to 464.

CONCLUSION

Clinical outcomes, such as pain scores, and opioid-related adverse effects, such as time to first bowel movement and nasogastric tube duration, may be linked with the amount of opioids used.

Failure-to-rescue and mortality after emergent pediatric trauma laparotomy: How are the children doing?

INTRODUCTION

Emergent trauma laparotomy is associated with mortality rates of up to 40%. There is a paucity of data on the outcomes of emergent trauma laparotomies performed in the pediatric population. The aim of our study was to describe the outcomes, including mortality and FTR, among pediatric trauma patients undergoing emergent laparotomy and identify factors associated with failure-to-rescue (FTR).

METHODS

We performed a one-year (2017) retrospective cohort analysis of the American College of Surgeons Trauma Quality Improvement Program dataset. All pediatric trauma patients (age <18 years) who underwent emergent laparotomy (laparotomy performed within 2 h of admission) were included. Outcome measures were major in-hospital complications, overall mortality, and failure-to-rescue (death after in-hospital major complication). Multivariate regression analysis was performed to identify factors independently associated with failure-to-rescue.

RESULTS

Among 120,553 pediatric trauma patients, 462 underwent emergent laparotomy. Mean age was 14±4 years, 76% of patients were male, 49% were White, and 50% had a penetrating mechanism of injury. Median ISS was 25 [13-36], Abdomen AIS was 3 [2-4], Chest AIS was 2 [1-3], and Head AIS was 2 [0-5]. The median time in ED was 33 [18-69] minutes, and median time to surgery was 49 [33-77] minutes. The most common operative procedures performed were splenectomy (26%), hepatorrhaphy (17%), enterectomy (14%), gastrorrhaphy (14%), and diaphragmatic repair (14%). Only 22% of patients were treated at an ACS Pediatric Level I trauma center. The most common major in-hospital complications were cardiac (9%), followed by infectious (7%) and respiratory (5%). Overall mortality was 21%, and mortality among those presenting with hypotension was 31%. Among those who developed in-hospital major complications, the failure-to-rescue rate was 31%. On multivariate analysis, age younger than 8 years, concomitant severe head injury, and receiving packed red blood cell transfusion within the first 24 h were independently associated with failure-to-rescue.

CONCLUSIONS

Our results show that emergent trauma laparotomies performed in the pediatric population are associated with high morbidity, mortality, and failure-to-rescue rates. Quality improvement programs may use our findings to improve patient outcomes, by increasing focus on avoiding hospital complications, and further refinement of resuscitation protocols.

LEVEL OF EVIDENCE

Level IV STUDY TYPE: Epidemiologic.

Chronic Disease Comorbidities Among Injured Patients in Cameroon: A Retrospective Cohort Study

INTRODUCTION

Chronic diseases are increasing but underdiagnosed in low-income and middle-income countries (LMICs), where injury mortality is already disproportionately high. We estimated prevalence of known chronic disease comorbidities and their association with outcomes among injured patients in Cameroon.

MATERIALS AND METHODS

Injured patients aged ≥15 y presenting to four Cameroonian hospitals between October 2017 and January 2020 were included. Our explanatory variable was known chronic disease; prevalence was age-standardized. Outcomes were overall in-hospital mortality and admission or transfer from the emergency department (ED). Associations between known chronic disease and outcomes were evaluated using logistic regression adjusted for age, gender, estimated injury severity score (eISS), hospital, and household socioeconomic status. Unadjusted eISS-stratified and age-stratified outcomes were also compared via chi-squared tests.

RESULTS

Of 7509 injured patients, 370 (4.9%) reported at least one known chronic disease; age-standardized prevalence was 8.4% (95% confidence interval [CI] 7.5%-9.2%). Patients with known chronic disease had higher mortality (4.6% versus 1.5%, adjusted odds ratio [aOR]: 2.61 [95% CI: 1.25-5.47], P = 0.011) and were more likely to be admitted or transferred from the ED (38.7% versus 19.8%, aOR: 1.40 [95% CI: 1.02-1.92], P = 0.038) compared to those without known comorbidities. Crude differences in mortality (11.3% versus 3.3%, P = 0.002) and hospital admission or transfer (63.8% versus 46.6%, P = 0.011) were most notable for patients with eISS 16-24.

CONCLUSIONS

Despite underdiagnosis among Cameroonians, we demonstrated worse injury outcomes among those with known chronic diseases. Integrating chronic disease screening with injury care may help address underdiagnosis in Cameroon. Future work should assess whether chronic disease prevention in LMICs could improve injury outcomes.

Comparison of Outcomes of Emergency Laparotomies Performed During Daytime Versus Nights and Weekends in Rwandan University Teaching Hospitals

BACKGROUND

Emergency laparotomy is a common procedure with high morbidity and mortality. The aim of this study was to assess if the time of surgery (day versus night and weekend) affects the morbidity and mortality in a low-resource setting.

METHODS

A retrospective study was conducted in 2 university teaching hospitals in Rwanda. Patient characteristics, time of laparotomy, operative details and postoperative outcomes were recorded. Chi-square and Wilcoxon rank sum tests were used to determine factors and outcomes associated with time of surgery. Logistic regression was used to determine factors associated with mortality.

RESULTS

In 309 patients, who underwent emergency laparotomy, 147 (48%) patients were operated during the daytime, 123 (40%) patients were operated during the night shift and 39 (12%) patients were operated on the weekend. Common diagnoses were intestinal obstruction (n = 141, 46%), peritonitis (n = 101, 33%) and abdominal trauma (n = 40, 13%). The overall mortality rate was 16% with 14% in patients operated during day and 17% in patients operated during night and weekends (p = 0.564). Overall, the morbidity rate was 30% with 27% in patients operated during the day compared with 32% in patients operated during night/weekends (p = 0.348). After controlling for confounding factors, there was no association between time of operation and mortality or morbidity.

CONCLUSION

Morbidity and mortality associated with emergency laparotomy are high but the time of day for emergency laparotomy did not affect outcome in Rwandan referral hospitals.

Health-Related Behaviours, HIV and Active Tuberculosis are Associated with Perioperative Adverse Events Following Emergency Laparotomy at a Tertiary Surgical Service in KwaZulu-Natal, South Africa

INTRODUCTION

This project aims to define the common comorbidities associated with patients undergoing emergency laparotomy in South Africa, to review the impact of these comorbidities on outcome and to attempt to model these various factors.

METHOD

A retrospective review of all patients undergoing emergency laparotomy for an emergency general surgical condition was performed from the prospectively entered Hybrid Electronic Medical Registry (HEMR). Univariate and multiple logistic regression analysis was performed to establish associations and independent risk factors for developing an adverse event.

RESULTS

Over a six-year time period, a total of 1464 patients underwent emergency laparotomy. The median age was 34 years. Males constituted 58.8% (861) of the patients and 754 patients (51.5%) experienced at least one adverse event. The mortality rate was 12 percent. Comorbidities and social factors were documented in 912 patients (62.3%). The rate of adverse events among patients with comorbidities was 59% (538). Patients without comorbidities or significant social factors had an adverse event rate of 39.1% (216). This difference was statistically significant (p < 0.001). The most frequent comorbidity in our sample was HIV, followed by hypertension, underlying malignancy, diabetes mellitus, active TB and cardiovascular disease.

CONCLUSION

Emergency laparotomy in South Africa is associated with significant morbidity and mortality. The patients are younger than in high-income countries. Diabetes mellitus, hypertension, HIV and active TB are associated with the development of an AE.