Incidence and predictors of perioperative mortality in a low-resource country, Ethiopia: a prospective follow-up study

Incidence and predictors of perioperative mortality in Ethiopia: a systematic review and meta-analysis

INTRODUCTION

The Lancet Commission on Global Surgery highlights perioperative mortality rate (POMR) as a key indicator of a nation's surgical system effectiveness. While POMR is often measured in high-income countries, it is less studied in low- and middle-income countries (LMICs). This study aims to assess the POMR and its predictors in Ethiopia.

METHODS

We conducted a thorough literature search across PubMed/MEDLINE, Embase, Web of Science, Scopus, and Google Scholar for studies from Ethiopia between 2019 and 2023 reporting POMR for various surgical procedures. Data were extracted in duplicate from eligible studies. We used random-effects meta-analysis to pool estimates of POMR and its predictors.

RESULTS

The meta-analysis revealed a POMR of 5.36%. Identified predictors of perioperative mortality in Ethiopia included older age, comorbidities, ICU admission, and an ASA physical status classification of III or higher and emergency surgeries.

CONCLUSION

Ethiopia's perioperative mortality rate is significantly high. Improving surgical care quality and safety, along with expanding access to surgical services, is crucial for bettering surgical outcomes in the country.

Retrospective analysis of general surgery outcomes in multicenter cohorts in Saudi Arabia

General surgery outcomes remain a concern despite advancements in techniques, anesthesia, and perioperative care. Achieving consistent, high-quality results and accurately predicting risks remains challenging. This study aimed to identify factors associated with adverse outcomes through a retrospective analysis of general surgery cases across multiple centers in Saudi Arabia. A retrospective cohort study analyzed 14,635 medical records of patients who underwent general surgery across multiple centers in Saudi Arabia from 2010 to 2020. Data from the General Directorate of Health Affairs registry included demographics, comorbidities, procedure details, and outcomes. The study focused on risk factors for 30-day mortality and complications, with subgroup analyses comparing outcomes across facilities. Common surgeries included hernia repair, cholecystectomy, appendectomy, and bowel resection. The overall 30-day mortality rate was 0.74%, and the complication rate was 11.1%. Independent predictors of mortality were ASA grade III/IV, Charlson index ≥3, cardiovascular disease, dementia, renal disease, and longer procedures. Teaching hospitals had lower mortality and complication rates. Complication predictors included older age, ASA III/IV, diabetes, cardiac disease, and high-risk procedures. Evening surgeries were associated with fewer complications. This multicenter study identified patient risk factors and procedure characteristics that predict 30-day outcomes after general surgery. Older age, multiple comorbidities, and high-risk surgeries were linked to poorer outcomes. Teaching centers had better results, emphasizing the role of institutional factors. These findings can guide risk stratification and quality improvement efforts to enhance recovery and provide a foundation for future research to improve surgical practices globally.

The effect of comorbidity on 28-day perioperative mortality rate among non-cardiac surgical patients in Northwest Ethiopia: a prospective cohort study using propensity score matching

BACKGROUND

Non-communicable diseases account for nearly three-fourths of global deaths impacting public health and development. Coexisting diseases can complicate the management of surgical diseases, increasing the risk of perioperative mortality. Despite this, few studies have examined the burden of comorbidities among surgical patients and their effect on perioperative outcomes in low-income countries. In this study, we assessed the impact of comorbidity burden on 28-day perioperative mortality using a prospective data set.

METHODS

This was a facility-based prospective cohort study. Adult patients aged ≥ 18 who underwent non-cardiac surgery were included. Patients were followed for 28 days following surgery. Perioperative data were collected using an electronic data collection system from June 01, 2019, to June 30, 2021, at Tibebe Ghion Specialized Hospital, Northwest, Ethiopia. A propensity score-matched analysis was employed to assess the effect of comorbidity on the 28-day perioperative mortality rate.

RESULTS

Of the 3030 patients included in this study, 715 (23.59%) had at least one comorbidity. Based on the prevalence rate, the top four comorbid conditions observed were hypertension (0.050), cancer (0.036), diabetes mellitus (0.021), and human immunodeficiency virus (0.021). The 28-day perioperative mortality rate was shown to be significantly higher among patients with comorbidity, where 45 (6.29%) of the 715 patients with comorbidity died compared to 49 (2.12%) of the 2315 patients with no comorbidity (p-value < 0.0001). After propensity score matching potential confounders, patients who have comorbidity had a 2.52% (average treatment effect on treated (ATT) = 0.0252) higher risk of perioperative death at 28 days after surgery compared with patients who did not have comorbidity.

CONCLUSION

This study found a moderate prevalence of comorbid illnesses among non-cardiac surgical patients, with comorbidity increasing the risk of 28-day perioperative mortality. Preoperative screening and optimization are highly recommended for patients with comorbid illness to decrease perioperative mortality rate.

Mechanisms and causes of death after abdominal surgery in low-income and middle-income countries: a secondary analysis of the FALCON trial

BACKGROUND

Death after surgery is devasting for patients, families, and communities, but remains common in low-income and middle-income countries (LMICs). We aimed to use high-quality data from an existing global randomised trial to describe the causes and mechanisms of postoperative mortality in LMICs. To do so, we developed a novel framework, learning from both existing classification systems and emerging insights during data analysis.

METHODS

This study was a preplanned secondary analysis of the FALCON trial in 54 hospitals across seven LMICs (Benin, Ghana, India, Mexico, Nigeria, Rwanda, and South Africa). FALCON was a pragmatic, 2 × 2 factorial, randomised controlled trial that compared the effectiveness of two types of interventions for skin preparation (10% aqueous povidone-iodine vs 2% alcoholic chlorhexidine) and sutures (triclosan-coated vs uncoated). Patients who did not have surgery or were lost to follow-up were excluded (n=231). The primary outcomes of the present analysis were the mechanism and cause of death within 30-days of surgery, determined using a modified verbal autopsy strategy from serious adverse event reports. Factors associated with mortality were explored in a mixed-effects Cox proportional hazards model. The FALCON trial is registered with ClinicalTrials.gov, NCT03700749.

FINDINGS

This preplanned secondary analysis of the FALCON trial included 5558 patients who underwent abdominal surgery, of whom 4248 (76·4%) patients underwent surgery in tertiary, referral centres and 1310 (23·6%) underwent surgery in primary referral (ie, district or rural) hospitals. 3704 (66·7%) of 5558 surgeries were emergent. 306 (5·5%) of 5558 patients died within 30 days of surgery. 226 (74%) of 306 deaths were due to circulatory system failure, which included 173 (57%) deaths from sepsis and 29 (9%) deaths from hypovolaemic shock including bleeding. 47 (15%) deaths were due to respiratory failure. 60 (20%) of 306 patients died without a clear cause of death: 45 (15%) patients died with sepsis of unknown origin and 15 (5%) patients died of an unknown cause. 46 (15%) of 306 patients died within 24 h, 111 (36%) between 24 h and 72 h, 57 (19%) between >72 h and 168 h, and 92 (30%) more than 1 week after surgery. 248 (81%) of 306 patients died in hospital and 58 (19%) patients died out of hospital. The adjusted Cox regression model identified age (hazard ratio 1·01, 95% CI 1·01-1·02; p<0·0001), ASA grade III-V (4·93, 3·45-7·03; p<0·0001), presence of diabetes (1·47, 1·04-2·41; p=0·033), being an ex-smoker (1·59, 1·10-2·30; p=0·013), emergency surgery (2·08, 1·45-2·98; p<0·0001), cancer (1·98, 1·42-2·76; p<0·0001), and major surgery (3·94, 2·30-6·75; p<0·0001) as risk factors for postoperative mortality INTERPRETATION: Circulatory failure leads to most deaths after abdominal surgery, with sepsis accounting for almost two-thirds. Variability in timing of death highlights opportunities to intervene throughout the perioperative pathway, including after hospital discharge. A high proportion of patients without a clear cause of death reflects the need to improve capacity to rescue and cure by strengthening perioperative systems.

FUNDING

National Institute for Health and Care Research Global Health Research Unit.

Augmented Reality (AR) in Surgery in Low- and Middle-Income Countries (LMICs): A Scoping Review

Surgical disparities persist in low- and middle-income countries (LMICs). Insufficient access to surgical care places a large burden on these regions, with high mortality rates for otherwise standard procedures performed in high-income countries (HICs). Augmented Reality (AR) and Virtual Reality (VR) now provide us with a platform to improve the delivery of surgical access and training to LMICs. The use of AR technologies to provide additional training to surgeons and residents globally can help bridge the gap and reduce health disparities in LMICs. The goal of this scoping review is to evaluate whether surgical trainees and surgeons from LMICs have access to or use AR software in their training or practice. A systematic search was conducted on seven databases. Inclusion criteria included populations in LMICs with access to AR-based training. Articles using VR software, or those conducted in HICs were excluded from the review. From the 428 records screened, 58 reports were assessed for eligibility, and of these, a total of six studies were included in the review. Five of the six studies used mentors from an HIC, including the United States (US) and the United Kingdom (UK), whereas one study had mentorship from another LMIC. Three surgical specialties were explored: neurosurgery, plastic surgery, and urology. Although the integration of AR in surgical training is promising, the six studies evaluated in this review emphasize that costs and connection issues are major challenges that can set back these technologies in the operating room. Despite these revelations, with certain improvements, AR training programs are promising as they can help to reduce the global disparity in surgical proficiency.

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.

Perioperative mortality rate and its predictors after emergency laparatomy at Debre Markos comprehensive specialized hospital, Northwest Ethiopia: 2023: retrospective follow-up study

BACKGROUND

Emergency laparatomy is abdominal surgery associated with a high rate of mortality. There are few reports on rates and predictors of postoperative mortality, whereas disease related or time specific studies are limited. Understanding the rate and predictors of mortality in the first 30 days (perioperative period) is important for evidence based decision and counseling of patients. This study aimed to estimate the perioperative mortality rate and its predictors after emergency laparatomy at Debre Markos Comprehensive Specialized Hospital, Northwest Ethiopia, 2023.

METHODS

This was a Hospital-based retrospective follow-up study conducted at Debre Markos Comprehensive Specialized Hospital in Ethiopia among patients who had undergone emergency laparatomy between January 1, 2019 and December 31, 2022. Sample of 418 emergency laparatomy patients selected with simple random sampling technique were studied. The data were extracted from March 15, 2023 to April 1, 2023 using a data extraction tool, cleaned, and entered into Epi-Data software version 3.1 before being exported to STATA software version 14.1 for analysis. Predictor variables with P value < 0.05 in multivariable Cox regression were reported.

RESULTS

Data of 386 study participants (92.3% complete charts) were analyzed. The median survival time was 18 days [IQR: (14, 29)]. The overall perioperative mortality rate in the cohort during the 2978 person-days of observations was 25.5 per 1000 person-days of follow-up [95% CI: (20.4, 30.9))]. Preoperative need for vasopressor [AHR: 1.8 (95% CI: (1.11, 2.98))], admission to intensive care unit [AHR: 2.0 (95% CI: (1.23, 3.49))], longer than three days of symptoms [AHR: 2.2 (95% CI: (1.15, 4.02))] and preoperative sepsis [AHR: 1.8 (95% CI: (1.05, 3.17))] were identified statistically significant predictors of perioperative mortality after emergency laparatomy.

CONCLUSIONS

The perioperative mortality rate is high. Preoperative need for vasopressors, admission to intensive care unit, longer than three days of symptoms and preoperative sepsis were predictors of increased perioperative mortality rate.