Death from scheduled surgery in Africa is a post-operative problem

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SurgeryDespite having a better risk profile than those in high-income countries, the risk of dying from scheduled surgery in Africa is more than double the global average, according to a 25-country study in The Lancet. Lead researcher Professor Bruce Biccard of the University of Cape Town pointed the finger at the post-operative phase, where 95% of surgery deaths occurred.

Patients who go under the knife in Africa in theory have a lower profile for risk than counterparts elsewhere, as they tend to be younger and are likelier to be admitted for minor rather than major surgery, Business Day reports the investigators found. But, they discovered, nearly one in five people who underwent surgery in Africa developed complications. In the case of elective surgery, the report says the death rate was 1.0%, compared with 0.5% in the global average.

The paper is described as the deepest and widest probe into surgery across Africa. It brought together more than 30 researchers who trawled through data from 247 hospitals in 25 countries.

The report says the main goal was to cover the outcome on 10,885 in-patient surgical procedures, a third of which were Caesarean sections. But the data net also included details about any complications, the number of beds, operating rooms and surgical staff, providing vital but fine-grained information about hospital infrastructure. More than four in every five patients could be considered low-risk candidates for surgery, as they were physically strong and were young, with an average age of 38.5 years. But complications, mostly entailing an infection, occurred in 18.2% of all patients. Nearly one in 10 (9.5%) of patients with complications died.

Lead researcher Bruce Biccard, a professor at Groote Schuur Hospital in Cape Town, pointed the finger at the post-operative phase, where 95% of surgery deaths occurred. Many of these fatalities could have been prevented, he said. “Many lives could be saved by effective monitoring of patients who have developed complications and increasing the resources necessary to achieve this objective,” Biccard said. “Surgical outcomes will remain poor in Africa until the problem of under-resourcing is addressed.”

According to the report, other experts said they were even more alarmed by other figures that turned up in the study: Africa’s glaring need for surgery. On average, just 212 operations were carried out per 100,000 people, said the commentary, authored by Anna Dare from the University of Toronto, Bisola Onajin-Obembe from Nigeria’s University of Port Harcourt and Emmanuel Makasa from University of the Witwatersrand. “These numbers are 20 times lower than the crucial surgical volume required to meet a country’s essential surgical needs each year,” they said.

On average, there were 0.7 surgical specialists – surgeons, obstetricians and anaesthesiologists – to every 100,000 patients in Africa, the study also found. This, too, is far below recommended levels of 20-40 specialists per 100,000 patients. Even though improvement in post-operative care is crucial, “the absence of surgery in Africa represents a silent killer that probably claims more lives,” the commentary said.

The report says the study included Algeria, Libya and Egypt in its scope, but did not include some of Africa’s poorest countries, such as Burkina Faso, Liberia and Sudan, or war-torn Somalia. Smaller remote hospitals, too, generally lay outside the data haul.

Background: There is a need to increase access to surgical treatments in African countries, but perioperative complications represent a major global health-care burden. There are few studies describing surgical outcomes in Africa.
Methods: We did a 7-day, international, prospective, observational cohort study of patients aged 18 years and older undergoing any inpatient surgery in 25 countries in Africa (the African Surgical Outcomes Study). We aimed to recruit as many hospitals as possible using a convenience sampling survey, and required data from at least ten hospitals per country (or half the surgical centres if there were fewer than ten hospitals) and data for at least 90% of eligible patients from each site. Each country selected one recruitment week between February and May, 2016. The primary outcome was in-hospital postoperative complications, assessed according to predefined criteria and graded as mild, moderate, or severe. Data were presented as median (IQR), mean (SD), or n (%), and compared using t tests.
Findings: We recruited 11 422 patients (median 29 [IQR 10–70]) from 247 hospitals during the national cohort weeks. Hospitals served a median population of 810 000 people (IQR 200 000–2 000 000), with a combined number of specialist surgeons, obstetricians, and anaesthetists totalling 0·7 (0·2–1·9) per 100 000 population. Hospitals did a median of 212 (IQR 65–578) surgical procedures per 100 000 population each year. Patients were younger (mean age 38·5 years [SD 16·1]), with a lower risk profile (American Society of Anesthesiologists median score 1 [IQR 1–2]) than reported in high-income countries. 1253 (11%) patients were infected with HIV, 6504 procedures (57%) were urgent or emergent, and the most common procedure was caesarean delivery (3792 patients, 33%). Postoperative complications occurred in 1977 (18·2%, 95% CI 17·4–18·9]) of 10 885 patients. 239 (2·1%) of 11 193 patients died, 225 (94·1%) after the day of surgery. Infection was the most common complication (1156 [10·2%] of 10 970 patients), of whom 112 (9·7%) died.
Interpretation: Despite a low-risk profile and few postoperative complications, patients in Africa were twice as likely to die after surgery when compared with the global average for postoperative deaths. Initiatives to increase access to surgical treatments in Africa therefore should be coupled with improved surveillance for deteriorating physiology in patients who develop postoperative complications, and the resources necessary to achieve this objective.

Bruce M Biccard, Thandinkosi E Madiba, Hyla-Louise Kluyts, Dolly M Munlemvo, Farai D Madzimbamuto, Apollo Basenero, Christina S Gordon, Coulibaly Youssouf, Sylvia R Rakotoarison, Veekash Gobin, Ahmadou L Samateh, Chaibou M Sani, Akinyinka O Omigbodun, Simbo D Amanor-Boadu, Janat T Tumukunde, Tonya M Esterhuizen, Yannick Le Manach, Patrice Forget, Abdulaziz M Elkhogia, Ryad M Mehyaoui, Eugene Zoumeno, Gabriel Ndayisaba, Henry Ndasi, Andrew K N Ndonga, Zipporah W W Ngumi, Ushmah P Patel, Daniel Zemenfes Ashebir, Akwasi A K Antwi-Kusi, Bernard Mbwele, Hamza Doles Sama, Mahmoud Elfiky, Maher A Fawzy, Rupert M Pearse

Business Day report
The Lancet article summary

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