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Perioperative Mortality Global Surgery Perioperative mortality: Analysis of 3 years of operative data across 7 general surgical projects of Medecins Sans Frontieres in Democratic Republic of Congo, Central African Republic, and South Sudan Jessica F. Davies, MBBS (Hons), DTMH, MSc,a Annick Lenglet, MSc, MAE,b Marten van Wijhe, MD, PhD,b and Cono Ariti, MSc,a London, United Kingdom, and Amsterdam, Netherlands Background. The African continent has the greatest burden of surgical disability-adjusted life years, yet the least is known about operative care here. This analysis describes the surgical patients admitted to 7 hospitals supported by the Medecins Sans Frontieres (MSF) over 3 years in 3 conflict-affected countries---Eastern Democratic Republic of Congo, Central African Republic, and South Sudan. Methods. A standardized operative data collection tool was used for routine collection of operative inpatient data between 2011 and 2013 at 7 MSF surgical facilities. Surgical records of 14,482 patients were analyzed to describe surgical epidemiology, major procedures, and perioperative mortality. The perioperative mortality rate (POMR) was calculated within 2 days of admission (POMR2) and within 30 days from admission (POMR30). The POMR is used as a marker of quality of operative care. Results. Caesarean delivery was the most common major procedure performed and had a POMR30 of 5.28 per 1,000 admissions. The overall inpatient mortality was 19.67 per 1,000 admissions. Children had greater POMR than adults for the same procedure types (47.97 vs 15.89 deaths per 1,000 admissions, P < .001); 85.1% of all major procedures were emergency procedures and between 3 and 30% of admissions were related to violence. After adjustment, perioperative death was associated with emergency surgery, violence, and age younger than 15 years. Conclusion. POMRs varied by age group and type of major procedure performed. Collecting surgical data is achievable and can inform future planning and support for national surgical programs. More information is needed on operative outcomes in adults and children in low-resource settings to improve quality and access to care. (Surgery 2016;159:1269-78.) From the London School of Hygiene and Tropical Medicine,a London, United Kingdom; and Medecins Sans Frontieres – Operational Centre Amsterdam,b Amsterdam, Netherlands OPERATIVE CARE is a key component of global health. approximately 2 billion of the world population Although surgical conditions account for an esti- lacks access to basic surgical care.1-3 The African mated 11% of the global burden of disease, continent has the greatest burden of disability- This study was funded by Med ecins Sans Frontieres–Operational Postbus 10014, 1001 EA Amsterdam, Holland. E-mail: Annick. Centre Amsterdam as part of routine monitoring and evaluation [email protected]. activities. The contribution of the first author was as part of her 0039-6060/$ - see front matter Master thesis work at the London School of Hygiene and Tropical Ó 2016 Elsevier Inc. All rights reserved. Medicine (LSHTM). http://dx.doi.org/10.1016/j.surg.2015.12.022 Accepted for publication December 22, 2015. Reprint requests: Annick Lenglet, MSc, MAE, Epidemiology Advisor, Medecins Sans Frontieres/Artsen Zonder Grenzen, SURGERY 1269 1270 Davies et al Surgery May 2016 adjusted life years at 38 per 1,000 people, yet little is some congenital anomalies should be available at known about basic general operative care in Africa.4 the district health services level.11 Humanitarian Where the burden of untreated operative disease is surgical outcomes are important, because they can known in sub-Saharan Africa, it is vast and underes- assist in planning future medical aid and provide timated.5 Approximately 288 million people are knowledge of the surgical epidemiology for popula- living with a surgically treatable condition, and a po- tions who otherwise have no or inadequate access to tential 5.6 million deaths could be avoided by access safe surgical care. to operative care each year.3 In validated, cluster, MSF has been present in the Democratic Republic randomized, cross-sectional countrywide surveys in of Congo (DRC) since 1981, in South Sudan since Sierra Leone, Rwanda, and Nepal, it was estimated 1983, and in the Central African Republic (CAR) that a quarter of respondents had a surgically treat- since 1996. All countries have been affected by able condition and that a quarter of household chronic violence and political instability with resul- deaths might have been avoided with access to safe tant population displacement and collapse of na- operative care.3,6 Basic procedures, such as tional health systems. The three countries are among Caesarean delivery and hernia repairs, are under- the lowest when ranked according to Human Devel- provided, and surgery remains inequitably distrib- opment Index, and in 2013 all three countries were uted amongst the poorest populations.2,7,8 considered “failed states.”21,22 Until recently, global surgery has remained a A perioperative mortality rate (POMR) has been relatively neglected area of public health in proposed as a credible indicator of access to and low-resourced settings. Increased research into safety of operative and perioperative care.23 The infrastructure, access, cost, resources, and safety most common definition for POMR according to of operative and perioperative care have aided the WHO is death after surgery and anesthesia within global health community to better understand the 2 time periods: the first point on the day of surgery barriers that limit surgical care in Africa. The (including death in the operating theatre) and the inclusion of basic surgery in the Disease Control second point either before discharge from hospital Priorities for Developing Countries and support or within 30 days of operation, whichever is from The World Health Organization (WHO) and sooner.24,25 Collection of operative data can be the Lancet Commission on Global Surgery have difficult in low-resourced settings because of major fuelled interest, support, and collaboration on limitations of the health information systems. operative care for low-income countries,9-11 but POMR is a widely reproducible measure that many obstacles remain to expanding surgical care does not require complex operative data. POMR in Africa, particularly in the crisis of human can overcome some of the variations in data collec- resources that is being addressed in large part by tion so that benchmarking and comparison can nonphysician providers.12,13 Operative care in the assist in improving operative safety. poorest countries of Africa often goes undocu- To contribute to the available evidence on surgi- mented, and it is important to disseminate and cal epidemiology in 3 conflict affected countries in share knowledge to aid planning of future inter- Africa, we described the surgical activities and ventions and support. This knowledge is particu- POMRs in 7 MSF-supported hospitals in the DRC, larly relevant, given the vast projections for CAR, and South Sudan between 2011 and 2013. increasing surgical burden across Africa by 2030, carried mostly by enormous increases in trauma METHODS and surgical care for noncommunicable diseases.1 Study sites. The 7 surgical hospitals included in Medecins Sans Frontieres (MSF) has been this analysis were located in eastern DRC (Mweso, providing operative care in low-resource settings Kimbi, Baraka, and Shamwana), northern CAR since its inception in 1971. Operative care has (Boguila), and South Sudan (Leer and Nasir) (Fig). remained a key focus for the organization, and These 7 projects were located similarly in chal- MSF has been a strong advocate for access to basic lenging environments in sub-Saharan Africa, subject affordable emergency medical care.14 Recent to frequent outbreaks of violence, and served a largely studies have quantified the burden of surgical con- unknown catchment population. All operative pro- ditions in several areas such as trauma, burn care, jects were run as a part of other health care programs pediatric care, surgery for infections, and Caesarean and were staffed largely by national surgical staff with deliveries.15-20 WHO recommends the provision of varying levels of training, except at both sites in South basic emergency surgical care for injuries and Sudan and Mweso (DRC) where the surgeons were trauma and obstetric and reproductive surgical con- expatriates. Anesthetic providers were trained nurses. ditions; nonemergency care for hernia repairs and All care was provided free of charge to the patient. Surgery Davies et al 1271 Volume 159, Number 5 Fig. Map of Central Africa showing relative locations of 7 MSF projects in CAR, South Sudan, and DRC. Data collection. A standardized surgical data underwent. A minor procedure was any procedure collection tool in Excel was used to collect indi- not under general or spinal anesthesia. Each vidual patient data on surgical inpatients admitted project independently defined specific surgery to MSF facilities from January 1, 2011 to December types as “options,” which were grouped under the 31, 2013. The tool collects information on the sex, title of “project specific options” and usually age, primary procedure undergone by the patient, included nonoperative management of trauma, number of procedures, duration of admission, burns, wounds, abscess drainage, and head urgency of operation, type of anesthetic, type of injuries. Defaulting patients were those who left exit from hospital and any resulting complications. hospital but were not discharged. Violence-related If a patient undergoes more than one operation injuries were only those considered resulting from during their hospital stay, the first and main intentional violence. Surgery (operative interven- procedure is recorded and information on the tion) was categorized into emergency surgery additional operations is not recorded in the (immediately life-threatening), surgery of infec- database systematically. The attending surgeon tion and neglect (imperative but not urgent), and recorded data postoperatively or after exit elective surgery. Elective surgery could include (discharge, death, default) of the patient. procedures that followed an initial emergency Definitions.
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