Surgical Care in Liberia and Implications for Capacity Building.

BACKGROUND: Situational needs of health care facilities inform the optimal allocation of resources and quality improvement efforts. This study examines surgical care delivery metrics at a tertiary care institution in Liberia. METHODS: We retrospectively reviewed operative and ward logbooks from January 1 to December 31, 2012. Data parameters included patients' age, diagnosis, procedure, mortality, and perioperative provider information. RESULTS: In 2012, 1,036 operations were performed. The breakdown of adult surgical cases reveals 452 (45.1%) general surgery operations, 192 (18.5%) orthopedic operations, and 180 (17.4%) ophthalmic operations. Other significant case volume included urologic 53 (5.1%), ENT 36 (3.5%), neurosurgical 31 (3.0%), vascular 24 (2.3%), and plastic 14 (1.4%) operations. Pediatric patients accounted for 24.5% (243) of surgical cases, and 9% of pediatric surgical cases were for hydrocephalus. General, spinal, and total intravenous anesthesia was provided by non-physician personnel, except when surgeons provided their own anesthesia. Ward logs documented 7.4% mortality among all patients admitted to the surgical ward, most of which occurred after exploratory laparotomy (44%), in burn (14%) patients, and in patients with head/neck emergencies (12%). CONCLUSIONS: This operative log review can be used to identify surgical practice patterns, needs, and deficits in order to inform the growth of surgical capacity at Liberia's only tertiary medical institution. Using this data to identify critical areas of high-yield operations (e.g., for pediatric hydrocephalus), or excessively high mortality rates (e.g., in burn care), can focus the direction of limited resources toward areas of need. While the heavy reliance on non-consultant surgeons reflects human capacity shortages and a pressing need for postgraduate training programs, identifying the breadth of surgical expertise demonstrated in these operative logs reveals the proficiencies required of surgeons to provide comprehensive surgical care in this setting.

Surgical outcomes for perforated peptic ulcer: a prospective case series at an academic hospital in Monrovia, Liberia

Introduction The incidence of perforated peptic ulcer remains high in low and middle-income countries. Mortality can be significant; and early surgical management with careful evaluation of pre-operative risk factors is essential. The purpose of this study was to describe the clinical outcomes of surgical treatment for perforated peptic ulcer disease in Liberia and to explore risk factors for adverse outcomes.Methods This study prospectively examined 20 consecutive patients undergoing primary closure with omental patch for perforated pre-pyloric or duodenal peptic ulcer at the John F. Kennedy Medical Centre (JFKMC) in Monrovia; Liberia from May 2009 to March 2010. Pre-operative information was captured in a questionnaire. Risk factors were assessed for univariate and multivariate associations with in-hospital mortality.Results Median age was 33 years and 85 were males. A majority of the patients (70) had a history of gastritis and antacid use. Median time from beginning of symptoms to surgery was 4.5 days. Over-all in-hospital mortality following surgical therapy for perforated peptic ulcer disease was 35. Median length of stay among survivors was 16 days; and death occurred at median 1 day after admission. Long symptom duration and age 30 years of age were significantly associated with in-hospital mortality on univariate (? = 2.60 [0.18-5.03]; p = 0.035) and multivariate testing (? = 2.95 [0.02-5.88]; p =0.049). Conclusion Peptic ulcer disease and its treatment represent a potentially substantial source of morbidity and mortality in limited-resource settings. In this case series; surgical treatment for perforated peptic ulcer disease carried a high mortality; and the results highlight the potential for public health systems strengthening to prevent poor health outcomes. Peptic ulcer disease in low- and middle-income countries presents unique epidemiology and treatment challenges that may differ significantly from evidence-based guidelines in high-income countries