Surgical mortality in Low Income Setting Eastern of DR Congo

Valimungighe MM, Vahwere BM, Ngavo WA, Wundiyohangi PK, Kalongo IM, Bisimwa MN, Sikakulya FK and Ketha JK

Published on: 2019-02-22

Abstract

Background: Every years, seven million surgical patients suffer from complications, including at least one million who die during or just after surgery. The objective of this work was to determine the overall mortality rate as well as to investigate the predictive factors of death in the surgical environment in the Katwa health Zone with a view to defining the prevention axes.
Methods: This was a retrospective descriptive and documentary study which took place in the urban-rural health zone of Katwa in Butembo, in the East part of the DRC from 1st January 2014 to 31st December 2016.
Results: The frequency of per and postoperative mortality was estimated to be 1.06% in this study. The predominance of male sex was found with a sex ratio of 2.9. The age range over 50 years was more concerned and half of the patients were farmer. Generalized acute peritonitis, digestive fistulas, and intestinal occlusions were observed, followed by tumors, gangrene, sores, and trauma. Per-and post-operative deaths occur in 75.19% of cases during the immediate and early postoperative period and causes of death are largely the septic shock followed by respiratory distress syndrome and hypovolemic shock in 53.49%, 28.68% and 8.53% respectively.
Conclusions: Mortality in the surgical environment is a real public health problem in Butembo city. The training of qualified personnel and the proper use of surgical safety tools could contribute to the reduction of this scourge. Septic shock remains a inevitable cause of this mortality in surgical setting.

Keywords

Mortality Surgical environment Katwa DRC.

Introduction

The operating room is a high risk environment for the patient. It appears as the main place of adverse effects in the hospital, because 43% of these are related to surgery [1]. Surgical emergency is a major public health problem in terms of morbidity and mortality. The prognosis depends on the early management [2]. According to World Health Organization (WHO) in 2008, surgical mortality rate was ranging from 0.4 to 10%, depending on whether it was in the developed regions or in the low, middle and income countries (LMICs) [3]. In the hospitals of developing countries in general, and in sub-Saharan Africa in particular, surgical emergencies are characterized by the delayed consultation and significant diagnostic and therapeutic difficulties. These difficulties are linked to the precariousness of the clinical state of the patients at the time of admission, and to the inadequacy or unavailability of certain data of biological examinations and imaging. All this contributes to the increase in the morbidity-mortality of these emergencies, which is between 15 and 33% [4]. In LMICs, emergencies always occur in an unfavorable socio-economic context and in an important medical underdevelopment. Taking charge of these emergencies, as practiced in industrialized countries, is difficult to apply in this context, but it is possible to adapt it to tropical specificities. These specificities are related to the condition of the patient (nutritional deficiencies), to its remoteness from the care structures, to self-medication, to the absence of health education and to the long consultation period, to the absence of medical transport, to the sub-equipment in Intensive Care Unit services, inadequate medical and paramedical personals and the absence of emergency-appropriate structures [5]. In these regions, the early post-operative evolution of digestive surgical pathologies has benefited from study on a case-by-case basis and is generally poorly appreciated [6]. A study conducted in Benin in a level II hospital showed a surgical mortality rate of 8.8% [7]. All these studies show the evidence of a discrepancy between the low mortality rate for some regions (0.4%) and the rate of high mortality in other regions such as our regions. Our work was therefore part of the problem of mortality in the surgical services in our region, taking into account this discrepancy demonstrated by the studies mentioned above. The main question was what the surgical mortality in our region is and what are the factors? The main objective of this work was to determine the overall mortality rate as well as to look for the predictive factors of death in the surgical environment in Katwa health Zone with a view to defining the axes of prevention.

Methods

Our study was carried out in the surgical, emergency and intensive care unit of Katwa health Zone, located in the city of Butembo and on the rural territory around of the said city among other things the general reference Hospital of Katwa, the Matanda hospital, the health centers of Wanamahika, Ngothe, Baraka, Sainte Famille and Mutiri. The study population was represented by 12085 patients admitted and having undergone one or more surgical procedures and the sample was exhaustive and non-probabilistic, consisting of 129 patients.
This was a retrospective, descriptive and documentary study spanning a period from 1st January 2014 to 31st December 2016. Included in this study were all patients who had consulted in our selected study structures and were operated and hospitalized in the surgical department. Excluded from this study were all patients who had not undergone a surgical procedure and all those underwent surgery but whose file was not complete. The information about each patient was collected from previously established individual fact sheets. Here are the variables considered for each patient: age, gender, address, health structure, intraoperative diagnoses, per-and post-operative death, cause of death in per and post operative period and re intervention. In order to judge the quality of the care and the post-operative resuscitation, we appreciated the early mortality if the deaths occurred between the first and the seventh postoperative day, and late if the death occurred beyond the seventh day after the surgery. Data entry and analysis was performed using the EPI INFO software version 7. The standards of ethics have been respected in the realization of this work. Confidentiality was guaranteed for all because a code was given to them instead of the name.
This was a retrospective, descriptive and documentary study spanning a period from 1st January 2014 to 31st December 2016. Included in this study were all inpatients who had consulted in our selected study structures and were operated and hospitalized in the surgical department. Excluded from this study were all inpatients who had not undergone a surgical procedure and all those underwent surgery but whose file was not complete. The information about each patient was collected from previously established individual fact sheets. Here are the variables considered for each patients: age, gender, address, health structure, intraoperative diagnoses, per-and post-operative death, cause of death in per and post-operative period and re intervention. In order to judge the quality of the care and the post-operative resuscitation, we appreciated the early mortality if the deaths occurred between the first and the seventh postoperative day, and late if the death occurred beyond the seventh day after the surgery. Data entry and analysis was performed using the EPI INFO software version 7. The standards of ethics have been respected in the realization of this work. Confidentiality was guaranteed for all because a code was given to them instead of the name.

Results

Mortality in the surgical environment in the urban-rural health area of Katwa

The table below outnumbers the frequency of surgical mortality in the urban-rural health area of Katwa health zone.

Intraoperative diagnosis

The table below shows the distribution of deceased patients according to the intraoperative diagnosis.

Cause of death in per and post-operative period

The following table shows the different causes of death and patients according to the post-operative death delay.

Re-interventions

The table below summarizes the re-interventions as well as the mortality rate associated with these re-interventions. 128 cases of re-interventions or a frequency of 1.06% were found.

Discussion

The frequency of per-postoperative mortality was estimated at 1.06% in our work. Our results are consistent with the conclusions established in studies published by the World Health Organization. In its publications, the crude surgical mortality rate is between 0.4% and 10% [3]. We have taken into account in our study 129 patients, of which 58.14% list at the hospital Matanda and 23.25% at the HGR of Katwa, then follow the other structures. Attipou et al. [8] and Musee et al. [9] had demonstrated in their studies that urban hospital centers have a high mortality rate compared to peripheral hospital centers and that accessibility to the hospital center could also be an influencing factor. For the Matanda hospital, this high rate would be due to geographical accessibility as it is located right in the city center and the road infrastructure allows rapid evacuation of the patients to this hospital. According to the peroperative diagnosis, it appears that the general acute peritonitis, digestive fistulas and intestinal occlusions are more observed with 48.84%, followed by tumors with 27.13%, gangrenes and pressure sores both with 8.53% and trauma with 5.43%. These results prove that in our study, non-traumatic abdominal pathologies are the most frequent and responsible of the mortality in the surgical environment in our region. Our results are different but not far enough from those of Allode SA et al who came to the conclusion that the providers pathologies of death were traumatic pathologies with 59.3%; then non-traumatic abdominal pathologies with 32.7% of cases [7]. With regard to the per-postoperative death period, it is apparent that per-and post-operative deaths occur in 75.19% during the immediate and early postoperative period. This would be due to immediate complications during the procedure or in the hours following the procedure and to complications that occur within 7 days after surgery. Kasall B et al. [5] in their study on management of emergencies cases at the Teaching Hospital in the tropics, the resuscitation deficit in the peri and post operative period increases the mortality rate. The causes of per-and post-operative death in our study was overpowered by septic shock (53.49%). Our results are close to those found by Otshudiema et al. at Panzi General Refferal Hospital in the East of the DRC. Indeed, in their study on re-interventions after abdominal surgery, this team had also found that the cause of death due to surgical procedure were overpowered by septic shock (58.8%) [10]. The result of our work shows that men were most affected by the re-interventions (54.7%). The most age affected by re-interventions was between 21-30 years old in 35.2% of cases. Acute peritonitis was more diagnosed in 60.2% of cases. Thirty cases of registered deaths, estimated mortality of 23.4% with the most common cause of death due to septic shock (60.9%) were found in this study. Our results are very close to those found by Otshudiema et al at Panzi. The latter found that female sex was most affected with 55.2% of cases, the most represented age was the age range between 21 to 30 years ago with 29.9% of cases and acute peritonitis were recurrent in 53.6%. The mortality rate was 25.4% with septic shock as the main cause of death in 58.8% of cases [10].

Conclusions

Mortality and morbidity in the surgical setting is a real public health problem in the Butembo city and need an urgent solution for the well being of this population. The under-equipment, lack of qualified and competent personals in management of surgical cases is a real handicap in the approach of surgical pathologies in our environment. Septic shock remains a inevitable cause of this mortality in surgical setting.

Conflicts of Interest

No conflicts of interest exist.

Funding

This work received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors

Authors Contributions

All authors contributed equally.

Acknowledgments

The author Joel KAMBALE KETHA thanks the charity society named Safe Anesthesia Worldwide -United Kingdom (SAWW-UK) for financial support in Master of Anesthesia and Critical Care at the College of Medicine of the University of Rwanda. We are also very grateful for the financial support of the society World Federation of Societies of Anesthesiologists -United Kingdom (WFSA- UK) throughout our training in Master of Anesthesia and Critical Care at the College of Medicine of the University of Rwanda.

References

1. Birgand G. Surgical site infections: original approaches to diagnosis and prevention. Pierre & Marie Curie University, 2014; 210.
2. Valimungighe MM, Bunduki GK, Kuyigwa MN, Ahuka OL. Etiologies of non traumatological abdominal emergencies surgery in butembo, Democratic Republic of the Congo. Int J Curr Adv Res. 2015; 4: 357-359.
3. WHO, Developing Countries (PED): Surgery, still a neglected health problem? In Surgery, data & principles for safer surgery, 2008.
4. Harouna Y, Ali L, Seibou A, Abdoul I, Gamatien Y, Rakotomala J, et al. Two years of emergency digestive surgery at the national hospital of niamey (niger): analytical and prognostic study. Med Afr Black. 2001; 48: 49-54.
5. Kasall B, Kane O, Diouf E, Beye MD. Emergencies in Teaching hospitals in a tropical environment: the point of view of the anaesthetist resuscitator. Med Trop. 2002; 62: 247-50.
6. Assouto P, Tchaou B, Kangni N, Padonou JL, Lokossou T, Djiconkpode I, et al. Early postoperative evolution in digestive surgery in tropical environment. Trop Med. 2009; 69: 477-479.
7. Allode SA, Hodonou MA. Morbidity and mortality in general surgery at a second level hospital in benin. Great Lakes Med Rev. 2017; 9.
8. Attipou K, Kanassoua K, Dosseh D. Non-traumatic abdominal surgical emergencies of the adult at Tokoin Teaching Hospital in Lomé (5-year assessment). J Rech Sci Univ Lomé (Togo). 2005; 7: 43-48.
9. Songne B, Kanassoua KK, Dosseh EDJ, Ayite A. Non-traumatic abdominal surgical emergencies of the adult operated at the hospital Saint Jean de Dieu d'Afagnan. J Afr Chir Digest. 2008; 8: 764-770.
10. Ottshudiema OG, Lobe LM, Ahuka OL. Re-intervention after abdominal surgery at Panzi General Referral Hospital in Bukavu, Democratic Republic of the Congo. Int J Curr Adv Res. 2017; 6: 1617-1620.

Tables

Table 1: Frequency of per-and post-operative mortality in health structures.

Health Structures

Patients who have undergone a surgical procedure

Cases of per-and post-operative mortality

 

%

Matanda

8600

75

0.62

Katwa

1300

30

0.25

H.C Wanamahika

432

3

0.02

H.C Mutiri

474

8

0.07

H.C Sainte Famille

435

4

0.03

H.C Ngothe

520

6

0.05

H.C Baraka

324

3

0.02

Total

12085

129

1.06

Table 2: Distribution of mortality cases according to intraoperative diagnoses.

Intraoperative diagnoses

n=129

%

Generalized acute peritonitis, digestive fistulas, and intestinal occlusions.

63

48.84

Tumors

35

27.13

Gangrene and pressure sores

11

8.53

Trauma

7

5.43

Cesarean section

3

2.32

Fractures

10

7.75

Table 3: Deaths by different causes.

Cause of Death

n=129

%

Septic shock

69

53.49

Respiratory distress syndrome

37

28.68

Hypovolemic shock

11

8.53

Cardiogenic shock

3

2.33

Allergy to anesthesia

2

1.54

Renal failure

7

5.43

Death Time

Early

97

75.19

Late

32

24.81

Table 4:  The re-interventions.

Variables

n=128

Percentage

Sex

Male

70

54.7

Female

58

45.3

Age

0-10

8

6.3

20-Nov

19

14.8

21-30

45

35.2

31-40

30

23.4

41-50

10

7.8

>50

16

12.5

Pre-operative Diagnosis 

Acute peritonitis

77

60.2

 obstetrical causes (Uterine rupture)

25

19.5

Intestinal occlusion and recto-vaginal

10

7.8

Inguinal Hernia

4

3.1

Others (tumors, cholecystitis, ovarian cyst,)

12

9.4

Number of re-interventions

32

25

≤2

83

64.8

4-Mar

13

10.2

>4

30

23.4

Evolution

98

76.6

Death

Recovered

78

60.9

cause of Death

50

39.1

Septic shock

 

100

 Other causes

128