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ORIGINAL ARTICLE
Year : 2022  |  Volume : 25  |  Issue : 7  |  Page : 1004-1013

Perioperative mortality among surgical patients in a low-resource setting: A multi-center study at District hospitals in Southeast Nigeria


1 Department of surgery, Alex Ekwueme Federal University Teaching Hospital, Abakaliki (AEFUTHA), Ebonyi State; Department of Surgery, Ebonyi State University, Abakaliki; District Hospital, Nsukka; Bishop Shanahan Specialist Hospital, Nsukka, Enugu State; Mater Misericordie Hospital, Afikpo, Ebonyi State, Nigeria
2 Department of surgery, Alex Ekwueme Federal University Teaching Hospital, Abakaliki (AEFUTHA), Ebonyi State; Department of Surgery, Ebonyi State University, Abakaliki, Nigeria
3 Department of surgery, Alex Ekwueme Federal University Teaching Hospital, Abakaliki (AEFUTHA), Ebonyi State; Department of Surgery, University of Nigeria, Nsukka, Nigeria
4 Department of Surgery, Ebonyi State University, Abakaliki; Mater Misericordie Hospital; Department of Anaesthesia, AEFUTHA, Afikpo, Ebonyi State, Nigeria
5 Department of surgery, Alex Ekwueme Federal University Teaching Hospital, Abakaliki (AEFUTHA), Ebonyi State, Nigeria

Date of Submission08-Mar-2021
Date of Acceptance02-Jun-2022
Date of Web Publication20-Jul-2022

Correspondence Address:
Dr. A U Ogbuanya
Department of Surgery, Alex Ekwueme Federal University Teaching Hospital, PMB 102, Abakaliki, Ebonyi State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_1291_21

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   Abstract 


Background: The perioperative mortality rate (POMR) has been recognized as a useful indicator to measure surgical safety at an institutional or national level. The POMR can thus be used as a tool to identify procedures that carry the highest mortality rates and provide hindsight based on past surgical experiences. Aim: To document the pattern of perioperative mortality and the factors that influence it at district hospitals in southeast Nigeria. Patients and Methods: This was a retrospective study of cases of perioperative mortality at district hospitals in southeast Nigeria between January 2014 to December 2018. All perioperative mortalities from surgical admissions in both elective and emergency set-ups were included. During analysis, we computed P values for categorical variables using Chi-square and Fisher's exact test in accordance with the size of the dataset. Furthermore, we determined the association between some selected clinical variables and mortality using logistic regression analyses. Results: During the period under review, 254 perioperative deaths occurred from 2,369 surgical operations, giving a POMR of 10.7%. Of the 254 deaths, there were 180 (70.9%) males and 74 (29.1%) females. Nearly one-third (31.2%) were farmers and 64.2% of the deaths occurred in those 50 years and below. Delayed presentation was two-pronged: delay before presentation and in-hospital delay. The POMR was the highest among general surgery emergencies and least among those with plastic surgery conditions. The observed factors associated with mortality were time of presentation (early or late), type of surgery (emergency or elective), category of surgery (general surgery or others), American Society of Anesthesiologists (ASA) score (high or low), place of admission after surgery (intensive care unit or general ward), level of training of doctors who performed the surgery (specialist or general duty doctor) (P < 0.05). Conclusion: The POMR was higher in male patients and in those with general surgery emergencies compared to other conditions. Delayed presentation, high ASA scores, and operations performed under emergency set-ups were associated with elevated POMRs.

Keywords: Emergency, laparotomy, perioperative mortality, predictors, surgery


How to cite this article:
Ogbuanya A U, Nnadozie U U, Enemuo V C, Ewah R L, Boladuro E O, Owusi O M. Perioperative mortality among surgical patients in a low-resource setting: A multi-center study at District hospitals in Southeast Nigeria. Niger J Clin Pract 2022;25:1004-13

How to cite this URL:
Ogbuanya A U, Nnadozie U U, Enemuo V C, Ewah R L, Boladuro E O, Owusi O M. Perioperative mortality among surgical patients in a low-resource setting: A multi-center study at District hospitals in Southeast Nigeria. Niger J Clin Pract [serial online] 2022 [cited 2022 Aug 19];25:1004-13. Available from: https://www.njcponline.com/text.asp?2022/25/7/1004/351438




   Introduction Top


Worldwide, the perioperative mortality rate (POMR) is one of the reference outcome measures against which surgeons judge the safety and the effectiveness of an operative technique. Other indices evaluated by the POMR are a surgeon's capacity and experience, anesthesia team performance, and the institutional organization network put in place to prevent avoidable deaths.[1],[2],[3] It has been observed that despite being younger, with a lower surgical risk profile, and undergoing less complex surgeries, patients in Africa have a POMR of 2.1% compared with figures of 0.8–1.5% at the global level.[3],[4],[5] In low- and middle-income countries (LMICs), outcome measures such as morbidity and mortality after operative surgeries are often elevated compared to the figures in developed nations.[6],[7],[8] Published data showed that major morbidity complicates 3–16% of all inpatient surgical procedures in developed countries with permanent disability or death rates of about 0.4–0.8%.[8] In developing countries, a death rate of 5–10% for major surgeries has been quoted.[8] Mortality from general anesthesia is reported to be as high as 1 in 150 in some parts of sub-Saharan Africa.[8]

It was noted that a scarce workforce and limited resources contribute to the lower surgical safety in Africa.[4],[9] A multinational prospective study involving 25 African countries and including 247 hospitals highlighted the barriers to safe surgery in Africa and recommended continent-wide quality improvement programs to reduce the number of preventable deaths following surgery in Africa.[4] From the foregoing, the unmet need for surgical services in Africa is enormous; yet, there are insufficient clinical data to point to this deplorable situation in a manner that surgeons and health managers working in the continent will be adequately informed. For instance, per population of 100,000 residents, Africa has the lowest number of specialist surgeons, anesthetists, and obstetricians in the world (0.5, 0.1, and 0.3, respectively, compared to Europe with values of 36.2, 15.7, and 18.2, respectively).[9] It is estimated that five billion people worldwide are unable to access safe surgical treatment, and 94% of these people live in LMICs, where nine out of ten people cannot access basic surgical care.[3],[10]

Briefly, the POMR, defined as the number of deaths that occur during or after surgery divided by the number of procedures performed, has been identified as a useful indicator to measure surgical safety at an institutional and national level.[1],[2] The most common definition of POMR according to the World Health Organization (WHO) is death after surgery and anesthesia within a two time-point period: the first point being on the day of surgery (including death in the operating theater) and the second point either before discharge from hospital or within 30 days of surgery.[2] It has been reported that 1 in 5 surgical patients in Africa develop complications, and overall, 2% of all patients are mortality cases.[3],[4],[10] In a recent African study involving a large series of surgical patients, 95% of deaths occurred postoperatively, suggesting that many of the deaths were avertable.[4] Several global initiatives by the WHO have been taken to limit the POMR, and notable among them are surgical safety checklists, the Lancet Commission on Global Surgery (LCGS), National Surgical, Obstetric and Anaesthetic Plan (NSOAP), WHO Global Initiative for Emergency and Essential Surgical Care, and Bellagio Essential Surgery Group.[10],[11],[12]

In sub-Saharan Africa, especially in rural settings, additional factors such as late presentation, a limited number of surgical personnel, inadequate treatment facilities, and poverty add to the weight of the burden that drive the high perioperative mortality rate.[2],[13],[14] It is only through surgical audit that a surgical team can learn from its past and incorporate the experiences into a more efficient, robust clinical strategy for the care of patients. There is limited data on this subject in our place and indeed in district hospitals in southeast Nigeria. It is hoped that data from this study will bridge the gap in the existing deficits and form a basis for advocacy and intervention. The aim of this study was to document the pattern of perioperative deaths and evaluate the etiologic spectrum at district hospitals in southeast Nigeria. The study also aimed to highlight important factors that are associated with increased POMR in our setting.


   Materials and Methods Top


Design and setting

This was a retrospective study of cases of perioperative mortality of patients managed under elective and emergency set-ups at district hospitals in southeast Nigeria between January 2014 to December 2018. The district hospitals were (i) District Hospital, Nsukka, Enugu State Ministry of Health, Enugu, Nigeria, (ii) Bishop Shanahan Specialist Hospital Nsukka, Enugu State, and (iii) Mater Misericordiae Hospital, Afikpo, Ebonyi State, Nigeria. There are other district hospitals in southeast Nigeria, but these three were selected because they are parts of the practice areas of the authors; moreover, there is high patient volume in the study centers.

Subjects/procedure

The clinical records from the theater operation registers and case files of all patients who were operated following admission into surgical wards, accident and emergency unit, surgical intensive care unit (ICU), and surgical amenity wards were retrieved and reviewed. Case files with incomplete data were excluded. Data extracted included sociodemographic parameters such as age, sex, educational status, occupation, and location of the settlement. The clinical diagnoses, mode of admission, and type of referral to the hospitals were noted. The occurrence of delay before presentation or in-hospital delay (delay between hospital admission and surgical operation) before treatment was noted, and the reasons for the delay were also recorded. The ASA scores of the patients, the status of the surgeon and anesthetist, and length of hospital stay (total duration of hospital admission) were noted and recorded. The number of dead patients were recorded and correlated with sex, age range, sub-specialty, mode of presentation (elective or emergency), status of surgeon and anesthetist, and degree of delay before presentation.

Ethical approval

The protocol for this study was approved by the “Ethical Research Committee” of the hospitals before the commencement of the study.

Data analysis

Data analysis was done using SPSS version 22.0 (IBM, Chicago, IL, USA, 2015). Data were presented in tabular and descriptive forms. Data were presented as mean, standard deviation, and percentages. The association between some selected clinical variables and mortality was determined using logistic regression analysis. A P value of <0.05 was used.


   Results Top


Characteristics of the study population

During the period of this study, a total of 2,426 case files of patients who had surgical operations were found. However, 57 (2.3%) files were excluded due to incomplete clinical data. Therefore, 2,369 case files met the inclusion criteria and comprised 1,312 (55.4%) males and 1,057 (44.6%) females. Their ages ranged from 2 to 79 years with a mean of 32.7 ± SD 16.24. Of the 2,369 patients, there were 254 deaths, representing an overall death per admission crude mortality rate of 10.7%. Out of the 254 deaths, males were 180 (70.9%) and females 74 (29.1%), giving a male to female ratio of 2.4:1. The distribution of the patients and deaths according to their ages and sex are shown below [Table 1]a.
Table 1a: Age and sex distribution
Table 1b: Impact of sociodemographic data on perioperative mortality rate.



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Nearly one-third, that is, 740 (31.2%) were farmers; others were traders 623 (26.3%) artisans 215 (9.1%), students 121 (5.1%), professionals 99 (4.2%), children with an age less than or equal to 10 years 299 (12.6%), and others 272 (11.5%). Nearly two-thirds, 163 (64.2%), of the mortalities occurred in those 50 years and below. The pattern of deaths showed double peaks in the age ranges of 21–30 years and 61–70 years. Of the 254 mortalities, 203 (79.9%) were rural or semi-urban dwellers, and the remaining 51 (20.1%) were residing in urban areas before admission. Approximately a tenth (25, 9.8%) of the mortality cases did not receive formal education; 120 (47.2%) and 85 (33.5%) had primary and secondary education, respectively. Of the remaining 24 deaths, 11 (4.3%) had tertiary education, whereas the educational history could not be properly ascertained in 13 (5.1%) cases. The impact of sociodemographic parameters on the POMR is shown below [Table 1]b.

Clinical presentation

The distribution of the patients and deaths according to the specialties is shown below [Table 2]. A majority of the patients presented for general surgical 964 (40.7%) and urologic 471 (19.9%) operations. Consequently, the highest incidence of deaths occurred in the general surgery 136 (53.5%) and urologic 361 (4.2%) patients [Table 2]. The impact of clinicopathologic parameters such as comorbidities, delayed presentation, ASA score, and emergency presentation on the mortality rate is shown below [Table 3]. The vast majority 2204 (93.0%) of the operated patients had significant delay before presentation. The reasons for the delays before and after presentation were multifactorial as shown below [Table 4]. Financial impediment was the most common reason for delay, representing 36.2% and 33.9% of all patients who had delay in pre-hospital and in-hospital periods, respectively. Approximately, one-quarter, 590 (24.9%), presented as emergencies. The main independent predictors of mortality among the studied patients were delayed presentation (P = 0.022), ASA class (P = 0.036), type of pathology (P = 0.043), and emergency presentation (P = 0.000).
Table 2: Distribution of mortality according to surgical specialty

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Table 3: Impact of some clinical indices on mortality

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Table 4: Reasons for delayed presentation and treatment

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Anesthetic assessment and treatment

A majority (1,482, 62.6%) of the patients belong to ASA I and II. The lowest number of surgical operations were recorded under ASA IV and V, but mortalities were the highest in these groups, at the rates of 21.2% and 60.2%, respectively [Table 3]. Of the 590 patients managed on an emergency basis, 512 (86.8%) had intervention within 72 hours of surgical admissions, and of these, 112 deaths were recorded. This gave rise to a crude mortality rate of 21.9% for a subset (512 patients) who were operated on within 72 hours of admission. Overall, the mortality rate in the first 72 hours of the emergency admissions was 19.0%. Of the remaining 78 patients, 22 deaths were recorded, giving a crude mortality rate of 28.2% for emergency cases that had intervention after 72 hours of hospital admission. For the 1,779 patients managed as elective cases, 1,645 (92.5%) had intervention after significant delays due to factors mentioned earlier. In those with elective presentations, there were 120 deaths, giving an overall mortality rate of 6.7% in the elective group.

Mortality Indices: Overall, the POMR in this study was 10.7%. The POMR was 13.7% for males and 7.0% for females (OR: 14.53; CI: 8.33–23.76: P = 0.018). For the emergency group, the POMR was 22.7%, but in the elective group, it was 6.7% (OR: 12.61; CI: 6.12–14.22; P = 0.000). There were significant statistical associations between mortality and delayed presentation (OR: 3,72; CI: 1.23–8.42; P = 0.022), high ASA score (OR: 6.52; CI: 2.75–9.36; P = 0.036), and general surgery operations (OR: 2.17; CI: 1.14–5.98; P = 0.042). In the emergency group, requirement for admission into the ICU after operation (P = 0.003), delayed treatment (P = 0.008), and referral from non-physician health workers (P = 0.014) were the main independent predictors of mortality [Table 5]
Table 5: Determinants of mortality in the emergency setting

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   Discussion Top


The mortality pattern in this study showed a predominantly agrarian and trading community with a male preponderance and an overwhelming majority of deaths occurring in the age group 50 years and below. Notwithstanding the overall higher number of deaths in the young, the relative crude mortality rates were higher in those aged 50 years and above compared to younger patients. Other sociodemographic factors that were associated with increased POMR were male sex, rural residence, and occupations such as farming or being an artisan. The majority of the deaths occurred in the general surgery unit, followed by urologic admissions. Emergency presentation, delayed presentation, ICU admission requirement postoperatively, anesthesia performed by nurse anesthetists, and operations executed by a lower rank of surgeons were associated with increased POMR.

Published data showed that the POMR is an important measure of access to safe surgical and anesthesia care in global surgery, and on this background, the WHO launched “Safe Surgery Saves Life” that later led to the “Safe Surgery Checklist” in 2009.[1],[3],[15] The overall crude mortality rate of 10.7% recorded in this study, although far higher than the global level of 0.8–1.5%, was comparable with the rates of 6.4–9.1% reported in other similar studies in Nigeria.[16],[17],[18] Elsewhere, in LMICs, rates of 20–27% have been quoted.[1],[19] The reasons adduced for the high surgical mortality in LMICs compared to developed nations were poor infrastructure, inadequate service delivery, and inefficient surgical and anesthesia workforce.[1],[19] In Tanzania, for instance, it was reported that of facilities providing basic surgery, only 20% of dispensaries, 25% of health centers, and 45% of hospitals had the minimum appropriate surgical equipment.[19] It was also found that only 50% of the facilities performing major surgeries have blood transfusion, ultrasound, and X-ray capabilities.[19] In the workforce, it was found that a majority of the surgery, obstetric, and anesthesia care was provided by non-physician clinicians (NPCs).[19] In the Kigoma and Mwanza regions of Tanzania, excluding the university hospital, 85% of cesarean section and other obstetric surgeries are performed by NPCs.[19] In 2012, 55.8% of non-obstetric major surgical procedures were performed by NPCs, whereas 87% of anesthesia providers in the country were NPCs.[19] Regarding service delivery, a service availability and readiness assessment report noted that 21% of dispensaries, 47% of health centers, and 79% of hospitals in Tanzania provided basic surgical care, but of these, only 27% of dispensaries, 33% of health centers, and 51% of hospitals were deemed to be ready for this service.[19] In consideration of the foregoing, a high surgical mortality will be the price for the deplorable infrastructure, low service delivery, and inefficient surgical and anesthesia personnel. Reports on the prevalence of emergency surgical conditions and the situation of safe surgery and anesthesia care in sub-Saharan Africa have continued to document dismal results, despite the WHO clamor for access to safe surgical and anesthesia services globally.[1],[20],[21]

It is noteworthy that the surgical literature in sub-Saharan Africa lacks robust discussions on surgical mortality generally and the POMR in particular.[1],[20],[21] A recent survey of surgical capacity in rural southeast Nigeria showed significant deficits in the five main domains of health services, namely, infrastructure, service delivery, training and workforce, economics and finance, and information management.[21] From the foregoing, we agree with the authors in their recommendation for activation of functional public–private partnership programs, revitalization of satellite hospitals affiliated to tertiary hospitals, enactment and enforcement of health laws, and improved budgetary allocation to health as strategies to reduce surgical mortality and improve surgical and anesthetic services to the rural dwellers in southeast Nigeria.[21] Recently, a multi-center African surgical outcome study found that despite being younger with a lower surgical risk profile and undergoing fewer complex surgeries, patients in Africa are twice as likely to die after surgery when compared with outcomes at the global level.[4] The reasons adduced were late presentation, poor diagnostic and treatment facilities, and limited workforce inherent in the African health sector.[4],[22],[23]

In the current study, general surgical cases, mostly generalized secondary peritonitis and abdominal trauma, were responsible for greater proportions of the deaths [Table 2]. Despite decline in the incidence of perforation peritonitis and abdominal trauma in developed nations, African nations and many LMICs have witnessed an increasing trend in recent time.[23],[24],[25],[26] Studies showed that mortality from generalized peritonitis is generally high and ranges from 10–34.7%.[25]

An important observation in this study was the positive correlation between the mortality rate and age. The increased rates of perioperative mortality with advancing age probably reflect the multiplier effects of comorbidities, diminished physiologic reserve, and more complex surgical procedures in older patients.[4],[5],[8] We also observed a double peak in the death pattern, first in the third decade and the second in the seventh decade of life. Perhaps, this may be related to the predilection of patients in the third and fourth decades to trauma and patients in the seventh decade or above to cancers and degenerative diseases.[4],[5],[20]

Published clinical studies have shown that trauma is the most common cause of death in the first four decades of life and contributes to 16% of the global burden of disease and 10% of mortality.[22],[23],[24] The explanation for the occurrence of the second peak may be two-fold, namely, the complex nature of oncological procedures and the high frequency of associated comorbid medical diseases in the elderly. It has been projected that 70% of the 24 million people predicted to have cancers by 2050 will live in LMICs and the majority will occur in middle-aged and elderly patients.[27],[28] Nevertheless, age has numerous modifiers and the events leading to mortality are predicated on several factors.[4],[5],[28] The factors include the stage of the disease, length of delay before presentation, physiologic state of the patients, level of preoperative preparation, availability of treatment facilities, safety check before and during surgery, experience of the surgeon and anesthetist, and the effectiveness of postoperative care.[4],[5],[28]

Our observation that the mortality rate was higher in males and that a vast majority of deaths occurred after the day of surgery overlapped with previous reports from Nigeria.[16],[17] Published data from similar studies outside Nigeria also support the above findings.[4],[5],[29] The higher incidence in males may be related to the higher incidence of injury-related deaths and higher-risk behaviors in males, namely, cigarette smoking, excess alcohol consumption, and other substances with significant health hazards.[22],[24],[28] In an African surgical outcome study involving 25 African countries, 95% of deaths occurred in the immediate postoperative period, compatible with 86.6% recorded in this study.[4] These findings suggest that many lives could have been saved by effective surveillance for physiological deterioration in patients who have developed complications, and increasing the resources necessary to achieve this objective remained a key strategy for POMR reduction in Africa and other LMICs.[4],[5] In a referral center in Chicago, USA, the impact of race on surgical mortality was evaluated.[30] Race was observed to be an imprecise proxy for social class, culture, and possibly shared life experiences, rather than a biological construct.[30] The authors cited advanced stage of disease, limited access to care, referral to high-mortality hospitals, and centers with higher frequencies of postoperative complications as drivers for the higher postoperative morbidity and mortality observed in African–American patients.[30] The authors concluded that race is merely a compass, not destination, perhaps indicating the direction where the clinicians and policymakers should look to address the disparity.[30]

A striking observation was the stratification of deaths across the surgical specialties with the highest death tolls recorded in the general surgery unit followed by urology. In a like manner, combined orthopedic and pediatric surgery cases were responsible for 20.5% of all deaths recorded in this study, whereas plastic and cardiothoracic surgery mortalities represented a negligible 3.1% of all deaths recorded during the study period. Reports of several studies from Africa agree with the above findings.[5],[7],[16] In Addis Ababa, Ethiopia, Firaol and colleagues reported on a large series of 350 mortalities from 10,259 surgical admissions.[7] Of these, 68.6% and 26.6% of the deaths occurred in general surgery and urology, respectively, akin to results from this study.[7] It is important to recognize that the higher number of death tolls in general surgery and urology is partly a reflection of the high patient volume in those specialties and may not necessarily indicate a higher POMR. Our observation that cardiothoracic surgery occupied a distant fifth with respect to the number of deaths recorded, yet responsible for the second-highest POMR, gives credence to the fact that the type and complexity of the pathologic condition are by far better predictive indices of mortality, rather than the surgical domain under discussion.

In the current discourse, no cardiothoracic or major procedures in abdominal, orthopedic, and urologic surgery were performed in the government-owned general hospital and this may explain the low POMR of 3.7% in that facility compared to a rate of 11.6% in the mission hospitals where the major procedures were performed (OR: 3.58; 95% CI: 1.42–8.33; P value: 0.002). The fact that the population served by the district facilities generally believes that government-owned general hospitals are ill-equipped and have a low workforce may be the reason why the presentation of most emergency and severe cases was skewed toward the mission hospitals with better diagnostic and therapeutic facilities. This, perhaps, led to higher hospital volume and management of severe surgical conditions arising from trauma, intra-peritoneal sepsis, cancers, and a gamut of other debilitating diseases in the mission hospitals and a subsequent increase in the POMR. In a recent review of the outcome of emergency laparotomy in rural southeast Nigeria, a comparable high postoperative mortality rate of 10.6% was reported.[31] Perhaps, the POMR in our environment is most likely predicated on the multi-faceted clinicopathologic profile of the surgical conditions as well as the preoperative patients' characteristics, hospital volume, surgeons' and anesthetists' experience, and the astuteness of the postoperative care.

Across Africa, the trend appeared uniform, although with minimal variations. In a recent African surgical outcomes study involving 25 indigenous African countries, general surgery mortality (33.8%) outstripped the others, followed by orthopedic surgery (11.3%).[4] In East-central Africa, Hewitt-Smith and co-workers found that although cesarean section accounted for 55.3% of all surgical procedures performed during the study, deaths from laparotomy alone accounted for 73.1%.[5] In patients undergoing laparotomy for trauma, intra-peritoneal sepsis, and visceral malignancies, the perioperative mortality risk indices are usually high, especially in developing countries like ours where delayed presentation, limited workforce, poor diagnostic and therapeutic facilities, poverty, and sub-optimal postoperative care are common.[5],[7],[31]

Generally, the problem of unrecognized postoperative physiological deterioration in surgical patients has been well described, prompting the development of such interventions as early warning scores, critical-care outreach, medical emergency teams, and critical-care skills training for junior surgeons.[4],[5] Regrettably, these programs are only fully operational in most high-income countries but are scarcely available in LMICs where POMR takes the highest toll.[4],[5],[8] In a recent pan-African study, it was recommended that a pragmatic continent-wide quality improvement program might improve the allocation of resources toward the postoperative surveillance of patients who are most at risk, and a simple surgical risk calculator could facilitate this approach.[4]

In the current discourse, several clinico-epidemiological factors were independently associated with increased mortality (P < 0.05). Importantly, the main predictors of mortality were delayed presentation, high ASA scores (III–V), laparotomy for trauma or peritonitis, emergency presentation, ICU requirement postoperatively, and surgical intervention after 48 hours of admission under emergency set-ups. Due to the retrospective nature of this study, an elaborate design to determine the full cause–effect relationships between these mortality indices and the POMR was not developed.

However, the Lancet Commission on Global Surgery was established to develop strategies for safe, accessible, and affordable surgical care, but implementation of this strategy has been largely diminutive in LMICs.[4],[10],[31] This may partly be explained by the lack of robust epidemiological data describing patterns of surgical activity and subsequent patient outcomes in LMICs, especially in sub-Saharan Africa.[4],[5],[10] Indeed, the peculiarities of perioperative deaths in African patients have become subjects of lively discussion. Although African surgical patients are younger than the global average with a lower-risk profile and lower complication rates, it is puzzling to find that African surgical patients are twice as likely to die during the perioperative period.[4],[5] It has been reported that approximately one in five surgical patients in African cohorts developed a postoperative complication and one in ten of these patients died.[4] It has been shown that many perioperative deaths occurring in LMICs are preventable using the standard of care.[4],[10],[12]

From the foregoing, a protocol prepared with consideration of the peculiarities of the African surgical ecosystem is salutary. It has been cited that persistent advocacies by policymakers and health managers coupled with intervention in the area of training and retraining of surgical personnel, formulation of public–private partnership (PPP) programs, and enactment of relevant laws (or enforcement of existing laws) should form important components of the African-oriented surgical strategies to improve the delivery of safe surgery and anesthesia.[21] On the global scale, a key strategy to reduce surgical morbidity and perioperative mortality was the development of the WHO safe surgery checklist in 2009.[15] A remarkable finding that none of the hospitals surveyed during this study routinely apply the WHO safe surgery checklist is worrisome akin to reports from Nigeria, Uganda, and Ghana.[3],[5],[6] It has been shown that significant adverse events take place in the operating theater and 43% of these mishaps were preventable using the current safe surgery checklist.[15]

Limitation

The study was retrospective in nature and therefore limited in its scope to accurately predict mortality. The heterogeneity of both the population and surgical specialties of the patients introduced an additional layer of limitation. Notwithstanding these limitations, the fairly large number of patients pooled over a 5-year period and the analysis of several clinicopathologic factors associated with perioperative mortality were the strengths of this study. Also, cases under neurosurgery were not encountered because the selected district hospitals did not undertake neurosurgical operations within the period under review. This may be related to a lack of adequate personnel and facilities. Also, data from only three district hospitals in southeast Nigeria were analyzed. Therefore, deductions made from the observations made in this study should be done with caution. The nutritional status of the patients was not taken into consideration as the data were collected retrospectively. This hampered the opportunity to determine the association between nutritional status and perioperative mortality.


   Conclusion Top


The POMR rate is higher in males and in patients over 50 years. The majority of deaths occurred in general surgery patients. Other main independent predictors of perioperative mortality included late presentation, high ASA scores, emergency presentation, ICU admission, and emergency surgical intervention after 48 hours of in-hospital admission. Public enlightenment campaigns on prevention of injuries, health education, provision of potable water and good road networks, and wider coverage of the National Health Insurance Scheme are salutary to reduce POMRs in our setting and other LMICs. A more robust prospective study on this subject is needed to generate an up-to-date and more representative data that can assist health policymakers and health managers make informed decisions.

Acknowledgements

We express our gratitude to the record personnel and management board of the selected institutions for their understanding and cooperation during the period of this study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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