Indications and Outcomes for Non-Trauma Emergency Laparotomy: A Comparison of Rwanda, South Africa, and the USA
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SURGERY IN LOW AND MIDDLE INCOME COUNTRIES
Indications and Outcomes for Non-Trauma Emergency Laparotomy: A Comparison of Rwanda, South Africa, and the USA Jennifer Rickard1,2 • Linda Pohl3,4 • Egide Abahuje1,5 • Nazmie Kariem3,4 • Surita Englbrecht3 • Christo Kloppers3 • Sekoaere Malatji4 • Isaie Sibomana5 • Alexandria J. Robbins2 • Kathryn Chu3,4,6
Accepted: 31 October 2020 Ó Socie´te´ Internationale de Chirurgie 2020
Abstract Background Emergency conditions requiring exploratory laparotomy (EL) can be challenging. The objective of this study is to describe indications, outcomes, and risk factors for perioperative mortality (POMR) after non-trauma EL. Methods This was a prospective study of patients undergoing non-trauma EL at four hospitals in Rwanda, South Africa, and the USA. Multivariate logistic regression was used to determine factors associated with POMR. Results Over one year, there were 632 EL with the most common indications appendicitis (n = 133, 21%), peptic ulcer disease (PUD) (n = 101, 16%), and hernia (n = 74, 12%). In Rwanda, the most common indications were appendicitis (n = 41, 19%) and hernia (n = 37, 17%); in South Africa appendicitis (n = 91, 28%) and PUD (n = 60, 19%); and in the USA, PUD (n = 16, 19%) and adhesions from small bowel obstruction (n = 16, 19%). POMR was 11%, with no difference between countries (Rwanda 7%, South Africa 12%, US 16%, p = 0.173). Risk factors associated with increased odds of POMR included typhoid intestinal perforation (adjusted odds ratio (aOR): 16.48; 95% confidence interval (CI): 4.31, 62.98; p value \ 0.001), mesenteric ischemia (aOR: 13.77, 95% CI: 4.21, 45.08, p value \ 0.001), cancer (aOR: 5.84, 95% CI: 2.43, 14.05, p value \ 0.001), other diagnoses (aOR: 3.97, 95% CI: 3.03, 5.20, p value \ 0.001), high ASA score (score C 3) (aOR: 3.95, 95% CI: 3.03, 5.15, p value \ 0.001), peptic ulcer disease (aOR: 2.82, 95% CI: 1.64, 4.85, p value \ 0.001), age [ 60 years (aOR: 2.32, 95% CI: 1.41, 3.83, p value = 0.001), and ICU admission (aOR: 2.23, 95% CI: 1.24, 3.99, p value = 0.007). Surgery in the US was associated with decreased odds of POMR (aOR: 0.41, 95% CI: 0.21, 0.80, p value = 0.009). Conclusions Indications for EL vary between countries and POMR is high. Differences in mortality were associated with patient and disease characteristics with certain diagnoses associated with increased risk of mortality. Understanding the risk factors and outcomes for patients with EL can assist providers in judicious patient selection, both for patient counselling and resource allocation.
This manuscript was presented at the College of Surgeons of East, Central and Southern Africa Annual General Meeting in Kigali, Rwanda on December 6, 2018. 3
Department of Surgery, University of Cape Town, Cape Town, South Africa
4
Department of Surgery, University Teaching Hospital of Kigali, Kigali, Rwanda
Department of Surgery, New Somerset Hospital, Cape Town, South Africa
5
Department of Surgery, University of Minnesota, 420 Delaware St SE, MMC 195, Minneapolis, MN 55455, USA
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