An analysis of neonatal mortality following gastro-intestinal and/or abdominal surgery in a tertiary hospital in South Africa

Background: The World Health Organisation estimates approximately 10% of neonatal deaths in sub-Saharan Africa and South Asia are due to congenital malformations. Neonatal mortality in the Republic of South Africa needs to be benchmarked against high income countries' (HIC) standard of care to identify means to reduce infant mortality, much of which is due to congenital anomalies amenable to surgical correction. Objectives: (1) Assess 30-day, 6-month and 12-month post-operative mortality for neonates operated for gastrointestinal and abdominal wall defects at a tertiary freestanding paediatric hospital in Western Cape, South Africa, over a 12-year period. (2) Ascertain the causes and risk factors associated with 30-day post-operative mortality. Method: A retrospective folder audit of all neonates that underwent gastrointestinal & abdominal wall surgery within the neonatal period at Red Cross War Memorial Children's Hospital (RCWMCH) during the 12-year period from 1 January 2007 to 31 December 2018. Results: The 30-day post-operative mortality rate was 73/762 (11%). Mortality was found in 9 conditions. An additional 57/762 patients (7%) died post-surgery between 30 days from surgery and 6 months of age. A further 34 patients (4%) died between 6 and 12 months of age. Mortality resulted from: sepsis (74%), palliation due to ultra-short bowel length (12%); in patients with necrotizing enterocolitis, intestinal atresia and malrotation with volvulus, ventilation associated pneumonia (10%), associated congenital cardiac lesions (3%) and intestinal failure associated liver disease (1%). Most neonates (69%) who died were prematurely born. Mean age at surgery was 10 days (median 6 days; interquartile range (IQR) 3-16) and mean age at death was 6 days (median 5 days; IQR 2-12; range 1-30). Nearly all patients who died were managed in the intensive care unit post-operatively (97%), with a median stay of 7 days (IQR 1-10) and overall hospital stay of 8 days (IQR2-12). Mortality in patients from referral hospitals more than an hour drive from RCWMCH was high (15/39, 38%). The odds ratio for death for patients with travel time over one hour from the referral hospital was 3.6 [95% confidence interval 1.8 to 7.3; z-statistic 3.6; p=0.0003]. The majority of surgical procedures in patients who died were for abdominal surgery 70/73 (96%). Surgery for necrotizing enterocolitis (NEC) had the greatest mortality (38%), followed by spontaneous intestinal perforation at (29%), gastroschisis (18%). Thirty-day mortality for oesophageal atresia, congenital diaphragmatic hernia and malrotation with volvulus was 9% each, followed by intestinal atresia at 8%, anorectal malformation (5%) and inguinal hernia (3%). No post-operative mortality was reported for Hirschsprung disease, choledochal malformation, hypertrophic pyloric stenosis, biliary atresia and omphalocele. Relook procedures were conducted for 37%, with the highest percentage of revision surgery for necrotizing enterocolitis at 42%. Abdominal compartment syndrome was noted post operatively in 15% patients. Significant modifiable risk factors for sepsis in patients who died were central lineassociated bloodstream infections (65%), respiratory tract infections (41%) and surgical complications [anastomotic breakdown (7%) and wound infection (24%)]. Conclusion: The 30-day post-operative mortality rate in this middle-income setting is similar to the overall mortality rate in HIC, despite excluding pre-operative mortality in this study. Prevention and improvement strategies for infection control are imperative to improve outcomes in surgical neonates, including optimizing timing of surgical intervention for bowel perforation or obstruction through timeous patient transfer for definite management and intensive care unit capacity optimization, central line care and post-operative infection surveillance. Liberal abdominal compartment pressure monitoring and delayed abdominal closure in selected patients may further reduce mortality. Addressing modifiable factors for morbidity and mortality in this vulnerable patient group is required for comparable outcomes to HIC

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Summary Background Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. Methods We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung’s disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. Findings We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung’s disease) from 264 hospitals (89 in high-income countries, 166 in middleincome countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in lowincome countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. Interpretation Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between lowincome, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030