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

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.

Diagnostic accuracy of fine needle aspiration cytology for palpable breast lumps in a Nigerian teaching hospital.

BACKGROUND: Breast lump is a very common problem in the surgical units of many hospitals. Considering our unique socio-cultural and economic peculiarities, the ideal initial preoperative diagnostic tool for breast diseases should be cost-effective, simple with minimal physical and psychological trauma. AIMS: This study aimed to evaluate the diagnostic accuracy of Fine Needle Aspiration Cytology (FNAC) in the management of palpable breast lesions in our center. METHODSOLOGY: This is a prospective study that lasted for one year. Fine needle aspiration cytology was done after clinical examination of all patients who gave consent. Open surgical biopsy was used as a reference standard. RESULTS: One hundred and fifteen patients were enrolled. We found that unsatisfactory smears (C1) were seven (6.1%), benign smears (C2), 57 (49.6%), atypical smears (C3), five (4.3%), suspicious of malignancy smears (C4), six (5.2%) and unequivocally malignant smears (C5), 40 (34.8%). Fine needle aspiration cytology achieved high sensitivity (90.4%), specificity (93.7%), positive predictive value (92.2%), negative predictive value (92.2%) and overall diagnostic accuracy (92.2%) for breast lumps in this study. The false positive and negative rates of 7.8% each are both higher than values recommended by National Health Services Breast Screening Program (NHSBSP) of United Kingdom. CONCLUSION: In view of the high sensitivity, specificity and overall diagnostic accuracy combined with early retrieval of pathologic results on first clinic visit reported in this study, FNAC should become a useful tool in the management of breast lumps in our center.

Elective Incisional Hernia Repair: Risk Factors and Evolution of Treatment in a Low-Income Setting.

BACKGROUND: The steady rise in laparotomy rates, particularly resulting from gynecologic and obstetric procedures in our environment has given rise to corresponding increase in the proportions of incisional hernias (IH). Over the years, discussion on the appropriate repair technique for IH has continued, nevertheless, with advances in laparo-endoscopy and introduction of prosthetic meshes, the surgical treatment has been revolutionized. AIMS: The aim of this study is to examine the risk factors and the evolutionary trend in surgical repair in our center. METHODOLOGY: This is a descriptive prospective study of adult patients with incisional hernias. The study was carried out in a tertiary health institution from January 2011 to December 2017. RESULTS: A total of 177 patients were recruited, 147 (83.1%) females and 30 (16.9%) males. Nearly two-thirds, 115 patients (65.0%) received prosthetic mesh repair, the rest, 62 patients (35.0%) were fixed using suture-based techniques. Among the 115 mesh repairs, 110 (995.7%) were in females and the remaining five (4.3%) were in males. The most frequent precipitating surgery was caesarean section in 72 patients (40.7%), followed by gynecology operations, 45 patients (25.4%), none-obstetrics and gynecology laparotomies, 50 patients (28.2%) and others, 10 patients (5.7%). Of the 177 patients evaluated, in 99 patients (55.9%) there was history of wound infection in the previous surgery while 24.9%, 5.1%, 4.5% and 1.1% reported that they had prolonged cough, diabetes, jaundice, and urinary obstruction in the peri-operative period of the initiating operations. The rate of recurrence was 17.7% in the non-mesh repairs and 0.0% in the group that had mesh repair. CONCLUSION: In our locality, the trend over time shows a shift from predominantly anatomic suture-based repair to a tensionless mesh implant with far lower recurrent rates. Laparotomy incisions for obstetric and gynecologic procedures are the most common precipitating incisions.

Emergency Presentation of Groin Hernia: Severity and Outcomes of Treatment in a Nigerian Tertiary Hospital.

BACKGROUND AND OBJECTIVE: Complications arising from groin hernias carry significant risks that task the resources of the surgeon and patient and, whenever feasible, should be avoided. In the past, obstructed groin hernia was the most common cause of intestinal obstruction in many parts of tropical Africa, but the trend appears to be changing. The aim of this study was to determine the severity and operative outcomes of complicated groin hernias in our centre. DESIGN: Aseven-year retrospective study. SUBJECTS: Records of adult patients with groin hernias, managed surgically for complicated groin hernias from January 2012 to December 2018 were retrieved and evaluated. RESULTS: A total of 387 patients were evaluated representing 18.3% of the entire groin hernias repaired surgically during the study period. Inguinal hernias accounted for 88.4% while femoral hernias represented 11.6%. Majority (76.5%) resided in a rural area. Twenty six (6.7%) patients presented with bilateral hernias (all were inguinal), but none had complications in both groins simultaneously. Twenty-one (5.4%) patients had spontaneous reduction, and of these, 13 (61.9%) received mesh implants. Overall, 6.2% were incarcerated, 56.8% were obstructed while the remaining 37.0% were strangulated. The resection rate was 29.5% for emergency repairs; 60.2% of the resections were performed in those who delayed beyond 72hours before presentation. The overall morbidity and mortality rates were 40.7% and 10.4% respectively. CONCLUSION: Late presentation is very common among patients with complicated inguinal hernia in our centre. Subsequently, bowel resection, morbidity and mortality rates are increased in proportion to the length of delay and degree of bowel and systemic involvements.

Antibiotic use among surgical inpatients at a tertiary health facility: a case for a standardized protocol for presumptive antimicrobial therapy in the developing world.

BACKGROUND: Indiscriminate antimicrobial use is one of the greatest contributors to antimicrobial resistance. A low level of asepsis in hospitals and inadequate laboratory support have been adduced as reasons for indiscriminate use of antimicrobials among surgical patients. At present, there are no guidelines for presumptive antibiotic use in Nigeria and sub-Saharan Africa. AIM: Surgical inpatients at the study hospital were surveyed to determine the level of antimicrobial use and degree of compliance with prescription quality indicators. METHODS: A cross-sectional survey was conducted among all surgical inpatients in May 2019 using a standardized tool developed by the University of Antwerp to assess the point prevalence of antimicrobials. Inpatients who were admitted from 08:00 h on the day of the survey were included. Data on patients' demographics, indication for antimicrobial use, reason for antimicrobial use, stop/review date, adherence to guidelines and laboratory use were collected. The prevalence of antimicrobial use in the surgical department was estimated. RESULTS: Eighty-two inpatients were included in the survey. Of these, 97.6% were receiving at least one antimicrobial agent. Only 5.4% of the prescriptions were targeted, and 37.6% of prescriptions were for empirical treatment of infections. Approximately half (50.7%) of the patients were receiving presumptive antibiotics, and 6% were receiving prophylactic antibiotics. In total, 58.7% of prescriptions were administered parenterally, and 98.2% of patients had documentation of a stop/review date. Metronidazole (P=32.3%, T=29.2%), ceftriaxone (P=28.4%, T=19.8%) and ciprofloxacin (P=14.2%, T=14.6%) were the most common antimicrobials used. CONCLUSIONS: There is a high rate of antimicrobial use among surgical inpatients, and the rate of indiscriminate antimicrobial prescribing among these patients needs to be reduced. This can be achieved by developing antimicrobial guidelines for presumptive antimicrobial therapy.