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Major surgery at Ayder teaching hospital- A retrospective 2 years analysis of operated surgical patients

Major Surgery at Ayder Teaching Hospital

2 Years Retrospective analysis of operated surgical patients

 

Investigators- 1. Girmay Hagos (Consultant thoracic and Vascular Surgeon)

               2. Goitom Berhane (BSc, in MSc training)

 

February 2011

 

 

 

 

 

 

 

 

 

Abstract

Introduction: There is a paucity of published data on the type of surgical conditions that affect the public in Tigrai set up and the spectrum of major surgical operations performed for these patients. Such information is necessary for assessing the impact of surgical conditions, both elective and emergency, on the public health and for setting priorities to improve the surgical care.

Methods and materials: Two years retrospective study of all surgical patients who were consecutively admitted to the surgical ward of Ayder teaching hospital, CHS, MU from June 22, 2008 to June 23, 2010 on whom major surgeries were done was conducted.

Results: A total of 1391 patients were admitted and operated for major surgery. The majority of these, 986(70.9%), were elective operations while 405(29.1%) operated patients were emergency cases. Male patients were more frequent than female patients with total counts of 923(66.4%) and 468(33.6%) with a ratio of 1.97:1.The first five most frequent admission diagnoses were goiter/thyroid nodules 161(11.6%), bowel obstruction 130(9.3%), acute appendicitis/appendiceal abscess 125(9%), bladder outlet obstruction/BPH 119(8.6%) and symptomatic cholelithiasis with count of 72(5.2%).There were a total of 36 major intra/postoperative complications of these 10 ended with mortality. General anesthesia, age beyond 61 and operation at emergency basis were significantly associated with severe intra/post-operative complications with c2=6.981(DF=1), p=0.008; 14.64(DF=4), p=0.005 and 10.026(DF=1), p=0.002 respectively.

Discussion and recommendation: As surgical pathologies are important public health problems, the required attention should be given for surgical care. And it should be among the priorities in the health system. There should be an institutional surgical care improvement for optimal outcome related to staffing, equipping and motivating the surgical team. Public health activities like accessing iodized salts universally and creating strong referral and feedback system among different hierarchies of health institutions is also mandatory. 

Key words: Ayder, Hospital, Retrospective, Surgery, elective, emergency

 

Introduction

The history of disease is at least as old as the history of mankind. In ancient Egypt, papyri have been found dealing with medicine, surgery, obstetrics and gynecology. The Edwin Smith papyrus written in about 1600 BC is one of the oldest and is of great interest to surgeons. The practice of surgery had evolved from the ancient primitive ways to the recent advanced surgical procedures through all these long time. (5)

Surgery is at the end of the spectrum of the classic curative medical model and, as such, has not been routinely considered as part of the traditional public health model. However, no matter how successful prevention strategies are, surgical conditions will always account for a significant portion of a population’s disease burden particularly in developing countries where conservative treatment is not readily available, where the incidence of trauma and obstetric complications is high, and where there is a huge back log of untreated surgical diseases (Murray & Lopez 1996). (11)

The burden of diseases worldwide due to surgical conditions alone is estimated to be 11% with the lead issues being injury, malignancy, congenital anomalies, and so on. However the surgical output is low in developing countries suggesting that there is a huge unmet need for surgical care. (7, 8)Each year, intentional and unintentional injuries account for nearly 1 in 10 deaths worldwide.(16)

By collecting pertinent data from patients’ medical records, substantial insight can be obtained in to the types of diseases, the age at which these disease conditions present, and their burden of inpatient service. Although these data are obviously referral and access based, they can provide useful information on morbidity in the community. (1)

Little is known about the surgical diseases that affect the community in Tigrai region. Data are lacking on the spectrum of surgical conditions, the morbidity and mortality associated with these conditions, and further more the burden of surgical diseases on the health system.

We analyzed the pattern of surgical pathologies, operative outcomes and the inpatient burden of patients who required major operations in Ayder teaching hospital, CHS, MU from June 22, 2008 to June 23, 2010.

 

 

 

Materials and methods:   

Background

 Tigrai region is the northmost of the nine ethnic regions of Ethiopia containing the home land of the Tigrayan people. Its capital is Mek’ele. This region is bordered by Eritrea to the north, Sudan to the west, the Afar region to the east and the Amhara region to the south.

Based on the 2007 census conducted by the central statistical agency of Ethiopia (CSA), the Tigrai region has an estimated total population of 4.5 million and an estimated area of 50,078.64 Km2. The region is predominantly Tigrayan, at 96.55% of the population; other ethnic groups include Amhara (1.63%), Irob (0.71%), Afar (0.29%), Agew (0.19%), and Kunama (0.07%). 95.6% of the population are Orthodox Christians, 4.0% Muslims, 0.4% Catholics, and 0.1% protestants.(3,4)

Ayder Hospital, under MU, CHS, is a teaching referral hospital for medical students, post graduate studies on surgery/obstetrics/gynecology, pediatrics/child health, infectious diseases, public health, and Nursing students.

            The surgical unit consists of a 100-bed general surgical ward, a modern operating block composed of 5 operating rooms and a recovery ward for immediate post-operative patients. The key technical staffs in this unit include two Surgeons, 5 GPs, 6 anesthesia technologists, 20 nurses (ward, scrub and utility nurses) with varsity experiences in surgical care.

Operational definitions- We used the following operationaldefinitions for the purpose of this study.

1. Major surgery: is surgery which penetrates and exposes any body cavity, including the cranium and the perineum (except castration), involves orthopedic surgery, or produces significant impairment of anatomical and/or physiologic function.
2. Elective surgery: is done to correct a non-life-threatening condition, and is carried out at the patient’s request, subject to the surgeon’s and the surgical facility’s availability. It is scheduled in advance because it does not involve medical emergency.( 13 )
3. Emergency surgery: is surgery which must be done promptly to save life, limb, or functional capacity.( 13)
4. Acute abdomen: an acute /recent onset of intra-abdominal process causing severe abdominal pain and often an urgent or emergent surgical intervention as its management.
5. Miscellaneous diagnoses: are variety types of surgical admission diagnoses with less than 10 frequencies of each that required major surgery as their management, like : hydatid cyst of the liver, chronic osteomyelitis,   

           

 

 

 

 

 

Data collection: Themedical records (patient files and operating room logbook) of all surgical patients who were admitted and operated in Ayder teaching hospital from June22, 2008 to June 23, 2010 were used to collect relevant data of variables after pre-testing a predesigned questionnaire by using 3 trained health staffs. For each admitted and operated cases, patient’s medical record number, age, sex, admission/preoperative diagnosis, date of admission and discharge/death/transfer, procedure done, post operative diagnosis, vital status of the patient were recorded in to questionnaires. Data of every numbered case were coded and entered in to Ms-Excel sheets. Analysis was done by SPSS-version 17.One way analysis of variance (ANOVA) was used to test for the significance in difference of the means of duration of hospital stay. c2-square tests and logistic regression were used to assess for significant association between major complications as outcome variable and other scale and categorical independent variables. Statistical significance was determined at P-value <0.05.

Results: From June 22, 2008 to June23, 2010, a total of 1391 surgical patients who were admitted to the surgical ward had undergone major operations at ATH. Of these cohort surgical patients 986(70.9%) had major surgery at elective basis while 405(29.1%) were emergency surgical cases. The majority of the surgical patients were male by sex comprising 923(66.4%) while the remainder 468(33.6%) were females with a male to female ratio of 1.97:1. The types of major operations and age distribution of these patients are shown in Fig.1 and 2 respectively.

 

 

 

 

 

The average patient age was 37.8 years. A total of 152(10.9%) surgical patients were pediatric age groups of <15 years of age. The highest proportion of patients, 430(30.9%), were under the category of age 31 through 45 years. The descriptive features of operated surgical patients are displayed in Table1. The five most frequent preoperative or admission diagnoses were goiter/thyroid nodules 161(11.6%), acute appendicitis/appendiceal abscess 130(9.3%), bowel obstructions 125(9%), bladder outlet obstruction/BPH 119(8.6%), & symptomatic cholelithiasis with a count of 72(5.2%). Over all diagnostic predictive value of the surgical unit for the operated patients was 97.8%, i.e. post operative and preoperative diagnoses were the same in 1361 patients and different in 30 patients. Of the total 36 (2.6%) severe complications; post operative sepsis accounts for 18, major bleeding 8, and other life-threatening complications (ARDS, burst abdomen, unexplained) 10.There were 10 deaths among all operated patients making the overall mortality rate of 7.2 per 1000 person-years. Predominant cause of death was multi-organ failure following sepsis and bleeding. General anesthesia, age beyond 61 and operation at emergency basis were significantly associated with severe intra/post-operative complications with c2=6.981(DF=1), p=0.008; 14.64(DF=4), p=0.005 and 10.026(DF=1), p=0.002 respectively (table5). Binary logistic regression has also revealed as age increases there is an increased risk of developing severe complication with AOR of 1.027(95%CI=1.006-1.049 and p=0.010).One way analysis of variance (ANOVA) for the average duration of hospital has shown that there was a significant difference in the means of duration of hospital stay for emergency (7.39 days) and elective (6.33 days) respectively (F=32.72, df=1, p=0.000).Major/poly-trauma had the largest average hospitalization duration ( 13.41 days ). There were a total of 9240 hospital days for surgical cases that had major operation during the two year period.

 

 

 

Table-1.The means duration of hospital stay in days with respective surgical diagnoses from June 22, 2008 to June 23, 2010, ATH, CHS, MU

Admission diagnosis

N

Mean

Std.Deviation

95%CI for the mean

Minimum

Maximum

Symptomatic cholelithiasis

72

6.56

1.005

(6.32,6.79)

3

8

GOO 2ry to PUD/Gastric cancer

56

7.38

1.421

(6.99,7.76)

4

16

Goiter/Thyroid nodule

161

5.30

.886

(5.16,5.44)

3

10

BPH

119

8.94

3.136

(8.37,9.51)

5

25

Bowel obstruction

130

6.53

3.063

(6.00,7.06)

2

23

Hernias (groin/incisional)

55

5.29

.916

(5.04,5.54)

3

8

Unspecified acute abdomen

43

6.86

1.505

(6.40,7.32)

5

11

Acute appendicitis/appendiceal abscess

125

6.25

1.554

(5.97,6.52)

4

12

Major/poly/ trauma

46

13.41

8.277

(10.95,15.87)

2

38

Breast masses/cancer

12

6.50

.905

(5.93,7.07)

5

8

Mediastinal/thoracic mass/esophageal stricture/cancer

5

10.40

5.683

(3.34,17.46)

2

17

Miscellaneous

377

6.00

2.420

(5.75,6.25)

2

22

Urolithiasis

14

6.71

1.684

(5.74,7.69)

3

10

pediatric congenital anomalies

18

6.11

1.811

(5.21,7.01)

3

10

Benign anorectal conditions

27

2.81

.834

(2.48,3.14)

2

5

Resolved appendiceal mass

7

5.00

1.000

(4.08,5.92)

4

7

Peripheral vascular diseases

13

5.54

2.066

(4.29,6.79)

3

9

Different Soft tissue masses

24

6.00

1.251

(5.47,6.53)

3

8

Redundant Sigmoid/stomies

23

6.35

.935

(5.94,6.75)

4

8

perforated PUD

12

7.17

.718

(6.71,7.62)

6

8

Generalized peritonitis

52

8.65

4.682

(7.35,9.96)

2

21

Total

1391

6.64

3.169

(6.48,6.81)

2

38

 

 

 

Table-2.Description of operated surgical patients with or without major intra/post-operative complications from June 22, 2008-June 23, 2210, ATH, CHS, MU

 

 

 

SN

 

 

Variable

 

 

Intra/post-operative complication

 

df

 

c2

 

P-value

 

 

No

Yes

 

 

 

1

Sex

Male

Female

 

898

457

 

25

11

 

 

1

 

 

0.158

 

 

0.691

2

Age category(years)

 

<15

16-30

31-45

46-60

61+

 

 

148

317

423

302

165

 

 

4

7

7

6

12

 

 

 

4

 

 

 

14.644

 

 

 

0.005

3

Type of Anesthesia

GA

SA

 

1157

198

 

25

11

 

 

1

 

 

6.981

 

 

0.015

4

Type of operation

Elective

Emergency

 

969

386

 

17

19

 

 

1

 

 

10.02

 

 

0.002

 

 

 

 

 

 

 

Age categories of operated surgical patients fromJune22,2008-June23,2010,ATH,CHS,MU

Age

Categories (in years)

Frequency

Percent

Valid Percent

Cumulative Percent

 

<15

152

10.9

10.9

10.9

15-30

324

23.3

23.3

34.2

31-45

430

30.9

30.9

65.1

46-60

308

22.1

22.1

87.3

61+

177

12.7

12.7

100.0

Total

1391

100.0

100.0

 

 

 

 

Discussion and recommendation

This study had reavelled that there is a prevailing wide variety of surgical diseases in our community.It is a well known fact that health facility data are an ice-berg clues for the huge problem in the community.Many of the surgical pathologies are benign and can be prevented before they cause ill health or their serious consequences can be averted if they are recognized early and managed on time.A classical example is “Goiter”- a benign thyroid gland enlargement following an iodine, micro-nutrient deficiency. This disease is nearly 100% preventable by making iodized salt universally accessible.Yet,in 21st century, it is shame that goiter is still a public health problem and one of the top admission diagnoses.These results also suggest that, in patients with emergency surgical pathology, the incidence of severe intra/post-operative complications was higher, increasing the length of stay in the hospital (ie, cost). A significant proportion of surgial condition causing major degree of ill-health, disability and mortality is trauma especially following road traffic accidents and of course with the largest mean hospital stay (13.41 days) indicating an increased work burden and increased cost incured. Surgical diseases are still a big burden in the health system and hence, to avoid salvageable life loss, disability and improve quality of life,surgical care should be given due priority with regard to awareness creation to the public, strengthening over all the surgical care: staffing, equipping, motivating.

Other prospective studies with both quantitative and qualitative aspects are required before giving definitive recommendations on the quality of surgical care the hospital is offering .

References

1. Debas HT. Gosselin R, etal. (2006) surgery in disease control priorities, 2nd ed. Oxford university press, NY PP1245-1260

2. http://www.who.int/surgery/mission/GIEESC 2005_Report.pdf

3. CSA-Ethiopia-2007 summary statistical report of population & housing census

4. Nordberg; E., S.Holmberg, &S.Kiugu, Output of major surgery in developing countries- Towards a quantitative evaluation & planning tool. Trop. Med, 1995.47(5):p206-11

5. M.A.R. Al-FALLOUJI, The candidate’s guide- postgraduate surgery 2nd Ed.p616-617

6. Paul E. Farmer. Jim Y.Kim (2008) – Surgery & Global health: a view from beyond the OR

7. Wright IG, Walker IA. Yacoub MH (2007).Specialist surgery in the developing world: luxury or necessity? (supp1) 84-8

9. http://www.encyclopedia.com/doc/1G2-3406200139

10. www.ucl.ac.uk/anesthesia/meetings/Text/2005/.Improving surgical outcomes and increasing clinical efficiency

11 Murray and Lopez – www.dcp2.org/pubs/DCP/67/Section/9771

12. Peden M. & Sharma G. A graphical overview of the global burden of injuries. Geneva, Switzerland: WHO 2002

13. Wikipedia- free encyclopedia

 

About the Author

1.Dr Girmay Hagos is chief thoracic and vascular surgeon in Ayder teaching referal Hospital ,Mekelle university, Mekelle Northern Ethiopia-emial; ” girmayhagos@yahoo.com

2.Mr Goitom Berhane is a postgraduate final year student in Emergency surgery and obs/gyn

  email-goitombh@yahoo.com

Recovering a Varsity aircraft from Sibson to Brooklands in 1988