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Background: A large burden of surgical disease is found in low- to middle-income countries, but only 3.5% of the 234 million major operative procedures performed annually in LMICs due to many challenges. Rwanda faces similar challenges observed in many other LMICs. One common major procedure that can give an indication of surgical provision is laparotomy, which has a high mortality rate in many Sub-Saharan African countries. However, little data exists on the outcomes of laparotomies in Rwanda, at all levels of surgical provision. Methods: This was a retrospective cohort study of patients who had laparotomy at the Centre Hospitalier Universitaire de Kigali (CHUK) between 2011 and 2013. Cases were identified using the operative logs. Patient characteristics and outcomes were collected from charts. Results: Records of 1276 laparotomy patients were analyzed; 827(65%) from general surgery and 449 (35%) from obstetrics and gynecology. Most patients transferred into CHUK, 1093(86%). The postoperative complication rate (POCR) was 29% (n=376) and the postoperative mortality rate (POMR) was 12% (n=153). Common predictors for POCR were home province, needing ICU care and having generalized peritonitis. General surgery patients had higher POCR if they had a high ASA score (OR 1.30 (95% CI: 1.12, 1.49)), were operated on between 12 and 6am (OR 1.99 (95% CI: 1.15, 3.45)) or had a pediatric congenital condition (OR 2.99 (95% CI: 1.04, 8.55)). ObGyn patients were affected by acuity of presentation (OR 4.47 (95% CI: 1.43, 13.98) and having a perforated organ (OR 5.13 (95% CI: 1.18, 22.23)). ASA score, home province and needing ICU care were significant predictors of high POMR in both groups. Pediatric patients with congenital disorders had an OR of 41.47 (95% CI: 4.47, 384.64)). ObGyn patients with generalized peritonitis had a significantly high OR of 14.90 (95% CI: 1.63, 136.5)). Discussion: The POCR and POMR observed were consistent with rates observed in previous studies from other sub-Saharan countries, which ranged from 14-33% complications rates and 10-30% mortality rates. POMR and POCR provide reliable and cost-effective metrics that are measurable and traceable, providing vital information about success or failure of implemented policies. Our study suggests hospital-specific and community level socioeconomic influences can be associated with surgical outcomes. Since provision of surgical care at the district hospital level may minimize delays in care provision, addressing district level socioeconomic and hospital factors may facilitate a holistic approach to improvement of surgical care in Rwanda. |
