Introduction

Non-traumatic childhood abdominal surgical emergencies (NTCASE) are common and their etiologies many. Some etilogies are acquired gastrointestinal diseases such as acute appendicitis, intussusception and perforation peritonitis, and congenital anomalies such as anorectal malformations and gastroschisis. In young children, aetiologies have been reported to have high mortality in developing countries (1). Among the leading causes of high morbidity and mortality in developing countries are delayed presentation and poverty (2). Electrolyte derangements occur more often in young children and may delay management. Other factors affecting mortality include ASA classification and haemoglobin level. Children constitute more than 40% of the population in most developing countries and therefore deserve a share of robust surgical care; thus, surgical services should be planned to reduce mortalities associated with these abdominal emergencies (2). Data on NTCASE is scarce at Moi Teaching and Referral Hospital (MTRH) and in Kenya. This study will act as a backbone of comparing data from MTRH with other institutions. This study aims to elucidate the various etiologies and immediate postsurgical outcomes in children managed for non-traumatic abdominal surgical emergencies at the MTRH and the factors correlated with mortality

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Methodology

A prospective descriptive study of children aged below 18 years presenting with non-trauma related abdominal emergencies at MTRH (surgical wards and newborn unit) between January 2015 to January 2016. The sample size was determined using Fisher et al. statistical formula (3) n = Z2pq / d2

Where:

n = desired sample size (when population is greater than 10,000).

Z = the standard normal deviate set at 1.96 which corresponds to 95% confidence level.

p = characteristic of the study population (10.1% mortality rate from previous data).

q = 1–p (in this case q=1.0–0.101).

d = the degree of accuracy desired, set at 5% or 0.05 corresponding to the 1.96.

A sample size of 140 was calculated.

Inclusion criteria:

• Children operated on for non-traumatic abdominal surgical emergencies at the MTRH.

• Children with a consent and assent for those above 7 years.

Exclusion criteria:

• Patients who had been operated elsewhere and then referred to MTRH

• Patients with obvious co-morbidities

The starting point of data collection was in the surgical wards and newborn unit after patients were identified from the theatre register. Patients who met the inclusion criteria were consecutively enrolled in the study. Data collection was conducted by the investigator and entailed filling questionnaire on clinical presentation, duration of onset of symptoms, investigations, supportive management and intraoperative findings as per case notes. Outcome evaluation parameters included complications, hospital stay and death. Daily follow-up was done until discharge or in-hospital death, either of which was taken as the end point of the study. All filled questionnaires were checked for completeness, and coded accordingly. Data was entered into an Access database and exported to SPSS version 20.0 for analysis. Continuous data were analyzed using means and standard deviation (SD). Categorical data were presented as frequency tables and charts. For binary data, Chi-square test and Fishers exact test were used for analysis. P-value of <0.05 was noted significant.

Ethical statement

This study was approved by IREC, FAN 1277. Approval from the MTRH was also sought and granted.

 

Results

Patients’ ages ranged from 1 day to 17 years, with a mean of 3.0 and SD of ±2.9 years. Neonates comprised 67 (65.7%) out of the 102 children. The male to female ratio was 2.1:1. Table 1 shows the diverse aetiologies identified. The average length of hospitalization and SD was 8.6±7.6 days, ranging from 1 day to 35 days. Overall in-hospital mortality was 20% (28 patients) with 24 being neonates (Table 2).

Click to view Table 1

 

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Outcome of NTCASE

The overall complication rate was 17.9% (n=25). Neonates constituted 19 of these 25 patients. Table 2 shows the specific complications identified.

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Click to view Table 3

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Factors co-related with mortality

Development of complications, duration of illness (<24 hours), ASA classification (grade 3,4), deranged potassium levels, normal hemoglobin levels (>12 g/dL) and neonates had significant co-relation with mortality (Table 4).

Click to view Table 4

 

 

Discussion

Congenital anomalies were more common; average age of children was lower compared with studies from India, Nigeria and Ghana (4-6). The tertiary nature of services offered may explain the difference in etiology and mean age when compared with studies from other developing economic regions. Gastroschisis, a serious congenital anomaly noted to be on the rise worldwide, is a significant burden in this region. Intussusception has maintained its burden as one of the commonest abdominal surgical emergencies not only in this region but also in most parts of the world (5,7,8).  The complication rate was higher in this study than in other studies (2,9). Patients who developed complications stayed significantly longer in the hospital. This could be because patients with surgical complications underwent another operation to solve the complication or to prolonged antibiotic therapy for some complications like septicaemia. Similar results have been reported by other authors (10). Also, patients with gastroschisis stayed longer in hospital due to having staged procedures in theatre at different times. The mortality rate in this study was also higher than in other studies (2,9). The highest mortality was in neonates, without any significant gender difference. Lack of adequate total parenteral nutrition and paediatric ICU facilities coupled with the low immunity and poor physiological body reserves in the phase of serious congenital and acquired disorders could be responsible for the high mortality and morbidity in children (2,11).  Most patients presented late (>24 hours). The effect can be noted by the higher mortality rate compared with other studies. However, presentation of <24 hours had a statistically positive correlation with mortality. This might be due to the low number of patients presenting before 24 hours and the rush to operate on them without sufficient resuscitation, and also to poor monitoring of these patients with the assumption that their vital signs and electrolytes had been normal prior to surgery. Other factors that affected mortality were age <2 years, anaemia, ASA classification grade 3 and 4, and deranged potassium levels. Despite correction of the deranged potassium levels (both high and low) before theatre, it had a positive co-relation with mortality (p<0.0005). Stabilizing electrolytes before taking patients to theatre is a basic regulation worldwide. Emphasis should be on early presentation of patient to avoid severe electrolyte derangements and aggressive resuscitation (2,5), and monitoring from admission till discharge. Neonates have intrinsic challenges like increased susceptibility to infections, hypocalcaemia, hypoglycaemia and poor cardiovascular reserves related to the transition from the foetal life to post-natal life. Trauma of surgery distorts the delicate balance, making them susceptible to sepsis, dyselectrolytemias, anaemia and nutritional deficits and respiratory complications (2).

 

Conclusion

The most common aetiologies of NTCASE at MTRH are intussusception and gastroschisis. Mortality and morbidity rates are clinically high. Factors co-related with mortality in patients with NTCASE are deranged potassium levels, ASA classification grade 3 and 4, neonates, normal hemoglobin level, duration of illness presentation <24 hours, and development of complications. Increased morbidity and mortality in children with non-traumatic abdominal surgical emergencies at MTRH can be reduced by considering the factors associated with them. 

 

References

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