The ASOS Surgical Risk Calculator: development and validation of a tool for identifying African surgical patients at risk of severe postoperative complications

BACKGROUND

The African Surgical Outcomes Study (ASOS) showed that surgical patients in Africa have a mortality twice the global average. Existing risk assessment tools are not valid for use in this population because the pattern of risk for poor outcomes differs from high-income countries. The objective of this study was to derive and validate a simple, preoperative risk stratification tool to identify African surgical patients at risk for in-hospital postoperative mortality and severe complications.

METHODS

ASOS was a 7-day prospective cohort study of adult patients undergoing surgery in Africa. The ASOS Surgical Risk Calculator was constructed with a multivariable logistic regression model for the outcome of in-hospital mortality and severe postoperative complications. The following preoperative risk factors were entered into the model; age, sex, smoking status, ASA physical status, preoperative chronic comorbid conditions, indication for surgery, urgency, severity, and type of surgery.

RESULTS

The model was derived from 8799 patients from 168 African hospitals. The composite outcome of severe postoperative complications and death occurred in 423/8799 (4.8%) patients. The ASOS Surgical Risk Calculator includes the following risk factors: age, ASA physical status, indication for surgery, urgency, severity, and type of surgery. The model showed good discrimination with an area under the receiver operating characteristic curve of 0.805 and good calibration with c-statistic corrected for optimism of 0.784.

CONCLUSIONS

This simple preoperative risk calculator could be used to identify high-risk surgical patients in African hospitals and facilitate increased postoperative surveillance.

CLINICAL TRIAL REGISTRATION

NCT03044899.

Perioperative patient outcomes in the African Surgical Outcomes Study: a 7-day prospective observational cohort study

BACKGROUND

There is a need to increase access to surgical treatments in African countries, but perioperative complications represent a major global health-care burden. There are few studies describing surgical outcomes in Africa.

METHODS

We did a 7-day, international, prospective, observational cohort study of patients aged 18 years and older undergoing any inpatient surgery in 25 countries in Africa (the African Surgical Outcomes Study). We aimed to recruit as many hospitals as possible using a convenience sampling survey, and required data from at least ten hospitals per country (or half the surgical centres if there were fewer than ten hospitals) and data for at least 90% of eligible patients from each site. Each country selected one recruitment week between February and May, 2016. The primary outcome was in-hospital postoperative complications, assessed according to predefined criteria and graded as mild, moderate, or severe. Data were presented as median (IQR), mean (SD), or n (%), and compared using t tests. This study is registered on the South African National Health Research Database (KZ_2015RP7_22) and ClinicalTrials.gov (NCT03044899).

FINDINGS

We recruited 11 422 patients (median 29 [IQR 10-70]) from 247 hospitals during the national cohort weeks. Hospitals served a median population of 810 000 people (IQR 200 000-2 000 000), with a combined number of specialist surgeons, obstetricians, and anaesthetists totalling 0·7 (0·2-1·9) per 100 000 population. Hospitals did a median of 212 (IQR 65-578) surgical procedures per 100 000 population each year. Patients were younger (mean age 38·5 years [SD 16·1]), with a lower risk profile (American Society of Anesthesiologists median score 1 [IQR 1-2]) than reported in high-income countries. 1253 (11%) patients were infected with HIV, 6504 procedures (57%) were urgent or emergent, and the most common procedure was caesarean delivery (3792 patients, 33%). Postoperative complications occurred in 1977 (18·2%, 95% CI 17·4-18·9]) of 10 885 patients. 239 (2·1%) of 11 193 patients died, 225 (94·1%) after the day of surgery. Infection was the most common complication (1156 [10·2%] of 10 970 patients), of whom 112 (9·7%) died.

INTERPRETATION

Despite a low-risk profile and few postoperative complications, patients in Africa were twice as likely to die after surgery when compared with the global average for postoperative deaths. Initiatives to increase access to surgical treatments in Africa therefore should be coupled with improved surveillance for deteriorating physiology in patients who develop postoperative complications, and the resources necessary to achieve this objective.

FUNDING

Medical Research Council of South Africa.

[Anesthesiological aspects and complications of intracranial meningiomas operated at the Sylvanus Olympio University Hospital Center, Lomé: about 21 cases]

This study aimed to point to both the anesthesiological aspects and the perioperative complications of intracranial meningiomas operated at the Sylvanus Olympio University Hospital Center, Lomé. We conducted a retrospective study by reviewing the medical records of patients with intracranial meningiomas undergoing surgery over the period December 2010-December 2015 (5 years) at the Sylvanus Olympio University Hospital Center, Lomé. Out of 46 patients operated fo brain tumors, 21 (45.6%) had meningioma. The average age was 49 ±20 years, with a male predominance (52.4%) and a sex ratio (M/F) of 1.1. Patients were classified according to ASA classification: 16 patients were classified as ASA II, 4 patients as ASA III and 1 patient as ASA IV. Patients underwent total intravenous anesthesia using hypnotic agent such as propofol (100%) and fentanyl (76.2%), which was the most available opioid. Perioperative complications were: bleeding, (mean blood loss: 1750 ±584 ml), hypotension (mean arterial pressure (MAP) < 60 mmHg) in 10 (47.6%) patients; hemorrhagic shock in 2 (9.5%) patients, cardiovascular arrest: 01 (4.7%) patient successfully resuscitated. Postoperative complications were: convulsions in 5 (23.8%) cases, hyperthermia in 4 (19%) cases, hemorrhagic shock in 2 (9.5%) cases, death in 2 (9.5%) cases. Perioperative morbidity and mortality associated with intracranial meningioma surgery at the Sylvanus Olympio University Hospital Center, Lomé remains high. Improvement of technical equipment and early consultation should reduce these complications.

[Epidural analgesia in 20 parturients at the Sylvanus Olympio University Hospital Center in Lomé (Togo)]

Etude prospective et descriptive sur la pratique de l’analgésie péridurale (APD) obstétricale au CHU Sylvanus Olympio (CHU SO) de Lomé. Etude menée de février à juin 2014. Après accord des gestantes choisies au hasard et en l’absence de contre-indication à l’issue de la consultation d’anesthésie, faite au 8ème mois de la grossesse, des femmes ont été retenues pour l’étude. Sur 29 gestantes retenues, 20 (69%) ont bénéficiées de l’APD. Age moyen 30,6±6,6 ans, primigestes : 35%, multipares 50%, Obèses (BMI>30): 25%. Nombre moyen de ponctions: 1,2±0,5; reflux de sang dans le cathéter: 5%, brèche dure-mérienne : 0. Délai moyen d’installation: 8,5 ±2,2mn. Quantité moyenne de bupivacaine isobare à 0,125%: 28,8±8ml; Echelle Numérique à T10min < 3 pour toutes les parturientes. Bloc moteur: 0. Hypotension: 1cas (5%). Mode d’accouchement: voie basse: 19 (95%), césarienne: 1 (5%). Détresse respiratoire à la naissance du nouveau né: 0. Note de satisfaction: 9,8±0,5 /10. L’APD obstétricale est possible au CHU Sylvanus Olympio de Lomé. En attendant sa vulgarisation à toutes les parturientes par la disponibilité des moyens humains et matériels, la réaliser pour ses indications médicales serait un premier pas.

Improvised Vacuum-Assisted Closure for severe neck infection in poorly equipped conditions

INTRODUCTION

Dental infections are common and are mainly due to dental caries. When left untreated, these infections can lead to severe life-threatening sepsis.

CASE REPORT

The authors reported a case of a severe odontogenic deep neck space infection in a 54-year-old male. The patient was a heavy smoker with incidentally discovered diabetes. He was successfully treated by surgical drainage combined with an improvised Vacuum-Assisted Closure (VAC) system. The results of surgical drainage followed by insertion of an improvised VAC system were spectacular. The abscess resolved in response to dual-agent antibiotic therapy on day 17 and blood glucose control was achieved with insulin. Full-thickness skin graft was performed to repair the necrotic zone of the neck.

DISCUSSION

The use of VAC can be a valuable alternative to conventional dressings and hyperbaric oxygen therapy in poorly equipped conditions. Public awareness campaigns remain the most effective form of prevention against these odontogenic infections.

[Neurological manifestations of Gougerot and Sjögren disease: a Black African case]

Primitive Gougerot-Sjögren syndrome (PGSS) is a systemic autoimmune exocrinopathy in which twenty percent of affected patients develop neurological manifestations. It has been little described in the Black African literature. We report a case of PGSS in a 64-year-old Black woman as revealed by neurological manifestations in an inflammatory context. Central neuropathy was present and the patient fulfilled at least four of the six Vitali American-European diagnostic criteria. There were abnormal aspects on the sylvian artery and hyperintense lesions of periventricular predominance. PGSS is a serious disease which we must consider when we encounter any unexplained neurological manifestations especially those associated with vasculitic lesions.

Incidence of hypoxia and related events detected by pulse oximeters provided by the Lifebox Foundation in the maternity unit at Sylvanus Olympio University Teaching Hospital, Togo

In recent decades anesthesia safety has not been improved in low-income countries. This prospective audit describes the incidence of hypoxia and related events detected among a cohort of patients undergoing surgery in the maternity unit at Sylvanus Olympio University Teaching Hospital, Togo, West Africa, by using pulse oximeters donated by the Lifebox Foundation. The Lifebox oximeter enables early detection of hypoxia for patients undergoing surgery before irreversible damage occurs. Pulse oximetry is cost-effective intervention and should be more accessible in all operating rooms of this type.

Extremity injuries in soldiers during the conflict in Mali: experience of Togo Level two Hospital

PURPOSE

The aim of this study was to analyse war-related and non-war-related extremity injuries in soldiers in the Mali conflict.

MATERIALS AND METHODS

This prospective study was performed from 1 May 1 to 31 December 2014. It concerned extremity injuries in soldiers treated at Togo Level 2 Hospital.

RESULTS

Seventy-nine patients with an average age of 31.19 years were assessed. Among them, 50 were admitted after war injury and 29 from nonwar injury. Most war-related injuries were due to improvised explosive devices (IEDs) (36 %); road traffic accidents (51.72 %) were the main mechanism of non-war injury. A total of 125 injuries were analysed. Limb fractures were identified in 37 patients (29.6 %), and 22 cases (59.46 %) were open fractures. Twenty-six (20.8 %) patients had soft tissue wounds. The other injuries were sprains (18.4 %), muscle contusions (15.2 %), dislocations (8.8 %), traumatic amputations (4 %) and burns (3.2 %). Surgical debridement and external fixator application were the most frequently performed surgical procedures. Thirty-nine per cent of patients were evacuated to a level 3 hospital for better care.

CONCLUSION

The severity of injuries and their rapid treatment require orthopaedic surgeons to have high levels of surgical experience and knowledge pertaining to military or disaster surgical doctrine.

[The gingivo periosto plastic surgery with osseous substitute: Technique and first results]

INTRODUCTION

Ortho dontico-surgical coverage of alveolar crack is essential in reason of its repercussions on facial growth and implementation of children's teeth set. We proposed to realize a premature gingivo periosto plastic surgery from 4 years old by osseous substitute to lower age of alveolar cracks closure and decrease the morbidity of patients.

PATIENTS AND METHODS

We conducted a retrospective study over one year (January, 2012 to December, 2012), with six months postoperatively outcomes, on 23 cases of gingivo periosto plastic sugary with osseous substitute type glass by bone transplant at infantile plastic surgery service of Timone - Children teaching hospital of Marseille, France.

RESULTS

We held 23 patients. Seventeen children, 12 boys and 5 girls presented unilateral cracks. Twenty patients required a quantity of glass bone under 1cc for the narrow cracks. Prevalence of the mucous cracks was low (4 cases on 23). Technique of gingivo periosto plastic surgery with osseous substitute is simple and our results are globally satisfactory. We observed less morbidity of the operating site.

CONCLUSION

The first results of this study showed that gingivo periosto plastic surgery with osseous substitute glass bone is a simple, reliable and reproducible technique, with promising results. Reduction of site's morbidity by osseous transplant, accessibility of glass bone cost and simplicity of surgical gesture justified adoption of this technique.

[Iatrogenic palatine necrosis by embolization of sphenopalatine arteries during management of a rebel epistaxis]

INTRODUCTION

The treatment of epistaxis sometime requires an embolization. This may result in ischemic palate necrosis, oronasal communication and dental losses. The repair of these lesions is complex.

OBSERVATION

A 53-year-old patient, suffering from high blood pressure and hypercholesterolemia, benefited from bilateral embolization of the sphenopalatine arteries in order to treat a persistent epistaxis. He developed a middle cerebral artery stroke in the aftermath. During the treatment of the neurological sequelae, a necrosis of the 2/3 of the posterior aspect of the hard palate was discovered. The angio-MRI showed an obstruction of both sphenopalatine arteries and of their vascular supplies resulting in a bilateral involvement of the alveolar bone. The diagnosis of iatrogenic palate necrosis was made. Tissue repair was successfully achieved by two loco-regional flaps. The dental rehabilitation was made by mean of a removable prosthesis.

DISCUSSION

Palatine necrosis following embolization of the sphenopalatine arteries is uncommon. Ischemia resulted in a loss of substance in form of a punch, similar to noma's lesions. It could also be a consequence of the vascular background. The management of these lesions is complex and calls for forensic reflection about the iatrogenic origin.

[Epidemiological aspects of limb fractures related to military exercises in Togo]

Le but de notre étude était de déterminer la fréquence des fractures de membres liées à l'exercice de la fonction militaire au sein des Forces de Défense et de Sécurité en milieu africain en vue de ressortir l'impact des différentes circonstances de survenue. Nous avons entrepris une étude rétrospective descriptive allant du 1er janvier 2004 au 31 décembre 2013. Elle a concerné les agents des forces de défense et de sécurité traités pour des fractures de membres au cours de cette période. Sept cent quatre (704) cas de fractures de membres ont été dénombrés. L’âge moyen des patients était de 30,57 ans avec des extrêmes de 19 et 55 ans. La prédominance masculine était nette (95,71%). L'Armée de Terre (51,05%) et la Gendarmerie Nationale (38,86%) étaient les plus représentées. Les hommes du rang étaient majoritaires (43,08%), suivis des sous-officiers (32,59%). La fréquence annuelle des fractures de membres en rapport avec la profession militaire était de 63 cas. Les fractures de jambe étaient les lésions les plus recensées (32,96%). Les Formations et les stages militaires ont été les circonstances de survenue les plus rencontrées (42,60%), suivies des accidents de la circulation (39,43%). La perte des journées de service liée à ces lésions était estimée à 14009 jours par an. Les fractures de jambes occupent le premier rang des fractures de membres en rapport avec l'exercice de la profession militaire. Les formations-stages militaires et les accidents de la voie publique en sont les deux grandes circonstances de survenue.

Post-operative pain management in paediatric surgery at Sylvanus Olympio University Teaching Hospital, Togo

BACKGROUND

The aim of this study was to evaluate pain management in paediatric surgery at Sylvanus Olympio University Teaching Hospital, Lome.

PATIENTS AND METHODS

A prospective descriptive study was conducted in the Department of Anaesthesiology and Intensive Care at Sylvanus Olympio teaching hospital from 1 January to 30 June 2012. Data collected include: demography, type of surgery, American Society of Anaesthesiologists (ASA) classification, anaesthetic protocol, analgesia technique, post-operative complications and cost of analgesia.

RESULTS

The study includes 106 post-operative children. Abdominal surgery was performed in 41.5% and orthopaedic surgery in 31.1%. A total of 75% of patients were classified ASA 1. General anaesthesia (GA) was performed in 88%. Anaesthetists supervised post-operative care in 21.7% cases. Multimodal analgesia was used in every case and 12% of patients received a regional block. The most frequently unwanted effects of analgesics used were nausea and/or vomiting in 12.3%. At H24, child under 7 years have more pain assessment than those from 7 to 15 years (46% vs 24%) and this difference was statistically significant (chi-square = 4.7598; P = 0.0291 < 0.05). The average cost of peri-operative analgesia under loco regional analgesia (LRA) versus GA during the first 48 h post-operative was US $23 versus $46.

CONCLUSION

Our study showed that post-operative pain management in paediatric surgery is often not well controlled and paediatric loco regional analgesia technique is under practiced in sub Saharan Africa.