Determinants of morbidity and mortality following emergency abdominal surgery in children in low- income and middle-income countries GlobalSurg Collaborative To cite: GlobalSurg Collaborative. Determinants of morbidity and mortality following emergency abdominal surgery in children in low-income and middle- income countries. BMJ Global Health 2016;1: e000091. doi:10.1136/ bmjgh-2016-000091 ▸ Additional material is available. To view please visit the journal (http://dx.doi.org/ 10.1136/bmjgh-2016- 000091). Received 18 May 2016 Revised 7 September 2016 Accepted 12 September 2016 Paediatric Surgery Unit, Department of Surgery, College of Medicine, Lagos University Teaching Hospital, University of Lagos, Lagos, Nigeria Correspondence to Dr Adesoji O Ademuyiwa; adesojiademuyiwa@yahoo.co. uk ABSTRACT Background: Child health is a key priority on the global health agenda, yet the provision of essential and emergency surgery in children is patchy in resource- poor regions. This study was aimed to determine the mortality risk for emergency abdominal paediatric surgery in low-income countries globally. Methods: Multicentre, international, prospective, cohort study. Self-selected surgical units performing emergency abdominal surgery submitted prespecified data for consecutive children aged <16 years during a 2-week period between July and December 2014. The United Nation’s Human Development Index (HDI) was used to stratify countries. The main outcome measure was 30-day postoperative mortality, analysed by multilevel logistic regression. Results: This study included 1409 patients from 253 centres in 43 countries; 282 children were under 2 years of age. Among them, 265 (18.8%) were from low-HDI, 450 (31.9%) from middle-HDI and 694 (49.3%) from high-HDI countries. The most common operations performed were appendectomy, small bowel resection, pyloromyotomy and correction of intussusception. After adjustment for patient and hospital risk factors, child mortality at 30 days was significantly higher in low-HDI (adjusted OR 7.14 (95% CI 2.52 to 20.23), p<0.001) and middle-HDI (4.42 (1.44 to 13.56), p=0.009) countries compared with high-HDI countries, translating to 40 excess deaths per 1000 procedures performed. Conclusions: Adjusted mortality in children following emergency abdominal surgery may be as high as 7 times greater in low-HDI and middle-HDI countries compared with high-HDI countries. Effective provision of emergency essential surgery should be a key priority for global child health agendas. Trial registration number: NCT02179112; Pre-results. INTRODUCTION Little data are available addressing the safety profile and risk factors affecting morbidity and mortality in children undergoing surgery globally. Most studies have been in adults and almost invariably were performed in high-resource countries. 1–3 Although it is estimated that about 234 million surgical pro- cedures are performed annually worldwide, the percentage of these involving children remains unknown. 4 Studies from low- and middle-income coun- tries (LMICs) have shown that in the neonatal period, mortality is associated with sepsis, mul- tiple exposures to anaesthesia (reoperation), postoperative bleeding and complex congeni- tal anomalies. 5–8 Other risk factors include non-availability of trained personnel, delayed presentation, childbirth outside a hospital and financial constraints of the caregivers. 9–11 Emergency surgery generally carries a higher morbidity and mortality compared with elective procedures. 12 13 An estimated 33 000 emergency laparotomies in all ages are per- formed annually in the UK with a 15–20% Key questions What is already known about this topic? ▸ There are little prospective data describing the outcomes of paediatric surgery in low-resource settings. ▸ Emergency surgery is associated with more deaths and complications than elective surgery, but most studies carried out until now are in adults. What are the new findings? ▸ After accounting for differences in case mix, the odds of death after emergency abdominal surgery could be as high as seven times greater in low-income countries compared with high- income countries. Recommendations for policy ▸ The provision of effective essential surgery should be a key priority for global child health agendas and has significant potential to impact on the global burden of disease. GlobalSurg Collaborative. BMJ Glob Health 2016;1:e000091. doi:10.1136/bmjgh-2016-000091 1 Research group.bmj.com on December 30, 2016 - Published by http://gh.bmj.com/ Downloaded from