T. Uribe-Leitz1, L. R. Maurer2, J. D. Jaramillo2, R. Fu3, M. M. Esquivel4, T. G. Weiser1,2 1Stanford University,Department Of Surgery, Section Of Trauma & Critical Care,STANFORD, CA, USA 2Stanford University,School Of Medicine,STANFORD, CA, USA 3Stanford University,School Of Engineering,STANFORD, CA, USA 4Stanford University,School Of Medicine/Division Of General Surgery,STANFORD, CA, USA
Introduction: WHO estimates that low income countries accounting for nearly 35% of the global population receive only 3.5% of all operations. Increased attention has focused on scaling up surgical services, yet post-operative mortality in these settings is unknown but likely to be high. Quantifying postoperative mortality is important to assess challenges in scaling up surgical services and improving care.
Methods: We performed a systematic literature review using Embase, Web of Science, Medline, SCOPUS and Google Scholar to identify articles reporting on mortality following cesarean section, appendectomy and groin hernia repair in low and middle income countries (LMICs) as defined by the World Bank. We included articles published since 2000 that reported mortality following one of these interventions, regardless of preoperative status, indication for intervention, or cause of death. We discarded duplicate analysis of the same data, reports on less than 10 operations, and laparoscopic-only studies. We aggregated studies by country to create larger data samples for analysis.
Results: Our initial literature search identified 1255 citations. After exclusion criteria, 203 required full-text review and 129 contained data for extraction. Forty two out of 116 LMIC published data on at least one of the predefined operations. We calculated crude post-operative case fatality rates (CFR) per country for each intervention. CFR ranged from 0 to 51.7 (mean=11.4) per 1000 operations for cesarean section, 0 to 88.6 (mean=13.5), per 1000 operations for appendectomy, and 0 to 411.8 (mean=39.9) per 1000 operations for hernia repair. This represents a 20, 5 and 15 fold increase in mean postoperative mortality when compared to Netherlands, a country with historically low CFR (cesarean section 0.58, appendectomy 3.03, and hernia repair 2.78 per 1000 operations).
Conclusion: Although these estimates do not control for comorbidities, demographics, or facility factors, our findings suggest tremendous variability in mortality following surgical intervention in LMIC. The excessive high death rates following essential surgical interventions indicate safety concerns that demand prompt attention.