African Journal of Paediatric Surgery About APSON | PAPSA  
Home About us Editorial Board Current issue Search Archives Ahead Of Print Subscribe Instructions Submission Contact Login 
Users Online: 281Print this page  Email this page Bookmark this page Small font size Default font size Increase font size 
 
 


 
ORIGINAL ARTICLE Table of Contents   
Year : 2013  |  Volume : 10  |  Issue : 3  |  Page : 226-230
Pattern, outcome and challenges of neonatal surgical cases in a tertiary teaching hospital


1 Department of Paediatrics and Child Health, University of Port Harcourt Teaching Hospital (UPTH), Port Harcourt, Nigeria
2 Department of Surgery, University of Port Harcourt Teaching Hospital (UPTH), Port Harcourt, Nigeria

Click here for correspondence address and email

Date of Web Publication1-Nov-2013
 

   Abstract 

Background: Globally, the major causes of neonatal deaths are birth asphyxia, prematurity and severe infections. Little attention is paid to deaths contributed by surgically amenable conditions. This study was undertaken to determine the burden and types of surgical problems encountered in the neonatal period, their outcome and challenges encountered. Patients and Methods: This was a retrospective study. The case notes of all neonates admitted into the newborn unit of our centre between April 2002 and March 2010 with surgical conditions were retrieved and the following information extracted: Sex, diagnosis, age at presentation, surgical intervention and outcome. Results: Out of 7,401 neonates admitted within the study period, 460 (6.2%) had a surgical condition. Of the 1,657 babies that died within the same period, 196 (11.8%) of them were those with surgical conditions. Congenital abnormalities accounted for 408 (88.7%) of all the surgical cases. Intestinal obstruction 129 (31.6%), neural tube defects 101 (24.8%) and anterior abdominal wall defect 58 (14.2%) were the commonest congenital abnormalities, while fracture of the long bones following birth trauma 15 (28.8%) and perforated NEC 14 (26.9%) were the commonest acquired conditions. Surgery was performed in 166 (36.1%) and 98 (59%) had postoperative complications. Significantly, more deaths occurred in preterms than in term babies (P = 0.003) and in those delivered outside the hospital than in in-born babies (P = 0.02). The major cause of death was infection in 92 (47%). Conclusion: Neonatal surgical conditions contributed significantly to both neonatal admissions and overall neonatal mortality and thus highlights the need for investments in newborn surgical care in developing countries.

Keywords: Congenital abnormality, neonate, outcome, surgical conditions

How to cite this article:
Ugwu RO, Okoro PE. Pattern, outcome and challenges of neonatal surgical cases in a tertiary teaching hospital. Afr J Paediatr Surg 2013;10:226-30

How to cite this URL:
Ugwu RO, Okoro PE. Pattern, outcome and challenges of neonatal surgical cases in a tertiary teaching hospital. Afr J Paediatr Surg [serial online] 2013 [cited 2019 Sep 16];10:226-30. Available from: http://www.afrjpaedsurg.org/text.asp?2013/10/3/226/120886

   Introduction Top


The major causes of neonatal deaths are birth asphyxia, prematurity and severe infections. [1],[2],[3] Little is known about the burden of neonatal surgical conditions on the overall neonatal mortality. In developed countries, outcome of neonatal surgical cases is favourable because of availability of antenatal diagnosis, improved surgical skills and technologies, sophisticated neonatal intensive care unit, availability of total parenteral nutrition and adequate staff. [4],[5] In developing countries, however, neonatal surgery is still fraught with a lot of problems including late presentation and lack of medical facilities and human resources, [6],[7] thereby, making newborn surgery to be associated with unacceptably high morbidity and mortality. Due to the burden of other neonatal and childhood diseases in developing countries, neonatal surgery is often considered low priority in healthcare budget planning and allocation. The aim of this study was to provide an insight on the burden and types of surgical problems encountered in our newborn unit as well as the outcome.


   Patients and Methods Top


This was a retrospective analysis of all neonates admitted into the newborn unit with a surgical problem between 1 st April 2002 and 31 st March 2010. The unit provides care for neonates with both medical and surgical conditions. It has an in-born and out-born section and is manned by two neonatologists and an average of three nursing staff per shift. The average monthly admission is 75 babies. The surgical cases were initially handled by the general surgeons and later by paediatric surgeons and a neurosurgeon. Available facilities include 10 incubators, 20 cots, five phototherapy units and two radiant warmers. The unit lacked ventilators, continuous positive airway pressure (CPAP) and had no access to total parenteral nutrition.

The case notes and the admission records in the newborn unit were used to extract the following information: Sex, age at presentation, gestational age at delivery, weight at birth or at presentation, place of delivery, antenatal care and diagnosis, diagnosis on admission/surgery, type of surgical intervention and outcome of management. Only cardiac defects confirmed by echocardiography are included. Congenital abnormalities like anencephaly which are not amenable to surgery were excluded. Data was entered in an Excel spread sheet and analysed using Epi Info version 3.5.1. Categorical data were analysed using the Chi-square test and a P-value ≤0.05 was regarded as significant.


   Results Top


A total of 7,401 neonates were admitted within the period made up of 4,191 (56.6%) males, 3,203 (43.3%) females and seven (0.1%) with ambiguous genitalia. Four hundred and sixty (6.2%) had a surgical condition made up of 265 (57.6%) males and 188 (40.9%) females, giving a male to female ratio of 1.4:1. Seven (1.5%) had ambiguous genitalia. The male preponderance, however, was not statistically significant (χ2 = 0.5; df = 1, P = 0.48). The mean age on admission was 120.29 hours ± 146.47 hours (range 30 minutes-27 days) and the mean weight was 2,900 g ± 2,200 g (range 900-5,600 g).

The total deaths within the period was 1,657 (22.4%) out of which 196 (11.8%) of them were those with surgical problems made up of 113 (57.7%) males, 79 (40.3%) females and four (2.0%) with indeterminate genitalia. The difference in the deaths among males and females was not significant (χ2 = 0.01; df = 1, P = 1.0). [Table 1] shows the general characteristics of the neonates. Two hundred and sixty-four (57.4%) of the mothers had antenatal care. Of the 125 (47.3%) mothers that had ultrasound done in pregnancy, only in 11 (8.8%) cases was the surgical condition diagnosed in the antenatal period and include omphalocoele (three), polycystic kidney (two), lumbosacral meningomyelocoele (two), congenital hydrocephalus (two), obstructive uropathy (one) and occipital encephalocoele (one). One hundred and forty (30.4%) of the neonates presented within 24 hours of life and were mainly babies with obvious defects.
Table 1: General characteristics of the neonates with surgical conditions

Click here to view


[Table 2] shows the types of neonatal surgical conditions and the systems involved. The commonest surgical conditions were due to congenital abnormalities in 408 (88.7%), whereas acquired causes constituted 52 (11.3%) of all the surgical cases. The systems most commonly affected were the digestive system 201 (43.7%), and the central nervous system 116 (25.2%). In 20 (4.3%), the abnormalities were multiple involving three or more systems. Congenital intestinal obstruction, neural tube defect and anterior abdominal wall defect accounted for 129 (31.6%), 101 (24.8%) and 58 (14.2%), respectively, of all the congenital surgical abnormalities, while fractures of the long bones following birth trauma and perforated necrotising enterocolitis (NEC) accounted for 15 (28.8%) and 14 (26.9%), respectively, of all acquired surgical conditions.
Table 2: Types of neonatal surgical conditions and the systems involved

Click here to view


[Table 3] shows the management and outcome. Death occurred in 196 (42.6%). Two hundred and ninety-four (63.9%) did not have surgery and 116 (39.5%) of them died (15 of them were considered ineligible for surgery because of their very poor clinical state and 101 of them while still being stabilized for surgery). A hundred and sixty-six (36.1%) had surgical intervention and 80 (48.2%) of them died after surgery, with 40 (50.0%) of the deaths occurring by the second day postoperatively. There was no significant difference in the number of deaths between those that had surgery and those that did not have surgery (χ2 = 1.12; P = 0.3). Surgery was done more for digestive system conditions and most of the deaths as well occurred in neonates that had surgery for a digestive system disorder. The commonest congenital abnormalities requiring surgery were anorectal malformation, small intestinal atresia (obstruction), neural tube defects and omphalocoele. The commonest surgical interventions were laparotomy with intestinal resection and anastomosis (either for small intestinal atresia or ruptured NEC) 46 (27.7%), colostomy 23 (13.9%), repair of neural tube defects 19 (11.5%) and closure of abdominal wall defect 17 (10.2%) [Table 4].
Table 3: Management and outcome of neonatal surgical cases

Click here to view
Table 4: Types of surgical intervention and associated mortality

Click here to view


Postoperative complications were seen in 98 (59%) and include infection in 68 (69.4%), anastomotic leak in nine (9.2%), burst abdomen in six (6.1%), enterocutaneous fistula in four (4.1%), short bowel syndrome in four (4.1%), acute renal failure in two (2%) and colostomy prolapse in two (2%). Intractable hypoglycaemia occurred in three (3.1%) as a result of difficult intravenous access from thrombosed vessels necessitating multiple venous cutdowns. Nine had a repeat surgery because of post-operative complications and seven (78%) of them died within 2 days of the second surgery. Significantly, more deaths occurred in preterm babies (34/41 for preterms vs. 162/419 for term babies χ2 = 8.84; P = 0.003) and those babies delivered outside the hospital (25/95 for inborn vs. 171/365 for out-borns χ2 = 5.22; P = 0.02). Sepsis was the commonest cause of death in 92 (47%) [Table 5].
Table 5: Major causes of mortality in 196 surgical neonates

Click here to view



   Discussion Top


The incidence of neonatal surgical conditions in this study was 6.2%. Although, surgical care is not considered an essential component of most child health programmes in developing countries, this high incidence demonstrates that neonatal surgical conditions are a significant public health problem. It was higher than the 3% reported in Tanzania, [8] however, the study was over a year period as against the present study that was over an 8-year period.

Congenital abnormalities accounted for over 80% of all neonatal surgical conditions. This was similar to the findings in other studies, [8],[9],[10] but in contrast to older children where acquired conditions were the commonest indication of paediatric surgical cases. [7] In a comparison of neonatal surgical admissions between two linked surgical departments in Africa and Europe, acquired surgical condition (NEC) was the commonest surgical condition in the Europe hospital whereas a congenital condition (anorectal malformation) was the commonest surgical condition in the African hospital. [11] The reason for this geographic difference is not readily explainable but it may be linked to better antenatal diagnosis in the Europe hospital.

The most common surgical conditions in the newborn involve the gastrointestinal tract. [12] This was the finding in this study and in other studies. [13],[14],[15],[16] The commonest congenital abnormalities requiring surgical repair were anorectal malformation, small intestinal obstruction, neural tube defects and omphalocoele, a finding similar to other studies. [16],[17]

The overall mortality in neonates with surgical condition in this study was 42.6%. Other authors had earlier reported lower mortalities ranging from 30.5% to 42.3%. [16],[17],[18],[19] The higher mortality in this study further suggests that survival of neonatal surgical cases is yet to improve. A higher mortality of 53.6% reported in another study [20] may be because most of the neonatal surgeries performed in that study were done under emergency condition when the neonate may not have been optimally stabilized. Infection was the commonest postoperative complications and the commonest cause of death as well just like in other studies. [17],[18],[20]

Significantly, more deaths occurred in preterm babies and those babies delivered outside the hospital. Mortality generally is known to be higher in preterm babies because of the immaturity of all physiologic functions. Babies delivered outside the hospital need to travel several hours to get to a specialist hospital that offers neonatal surgical services during which time the baby's condition may deteriorate, leading to increased operative risk and mortality. The mortality is also often related to the promptness of diagnosis, the complexity of the surgical condition, the type of surgical procedure and presence of complications. Laparotomy for intestinal resection and anastomosis (either for small intestinal obstruction or ruptured NEC), closure of ruptured omphalocoele, colostomy, thoracostomy with oesophageal anastomosis, and multiple abnormalities were associated with high mortality, a finding similar to that in another study. [20]

Factors that probably affected the outcome adversely include lack of antenatal diagnosis such that deliveries of these children were not planned and the children transferred immediately to centres that can offer surgical care. Only 47.3% of the supervised deliveries had ultrasound examination in pregnancy with only 8.8% of the congenital surgical condition diagnosed in the antenatal period. This low level of antenatal ultrasound scan and diagnosis was also noted in India. [21] Over 75% of the babies were delivered outside the hospital and had to be transported to the unit without resuscitation. The result is that these children presented late when metabolic and medical conditions would have set in to compound the surgical problem. Lack of adequate staff and appropriate facilities like ventilators and total parenteral nutrition also played a role. Delay in presentation, shortage of personnel and inadequate facilities as being the major problems associated with management of neonatal surgical patients were also identified in other studies. [3],[9],[17],[19] Early recognition and immediate treatment of surgical conditions in the newborn infant is, therefore, very important.


   Conclusions Top


Neonatal surgical cases constituted 6.2% of the total admissions and 11.8% of all deaths in our newborn unit. Congenital abnormalities, especially those involving the digestive and central nervous systems, accounted for the majority of the surgical conditions seen in neonates. Majority of the babies presented late-time enough for other metabolic and medical complications to set in and adversely affect the outcome. Antenatal diagnosis with early referral, improved surgical skills and technologies, adequate staff and post-operative care as well as investments in developing neonatal surgery subspecialty are all required to reduce mortality and ensure a better outcome for surgical neonates in developing countries.


   Acknowledgment Top


The authors wish to thank the nurses and the doctors who assisted in the retrieval of the folders and the required information.

 
   References Top

1.Ugwu RO, Eneh AU. Mortality in the special care baby unit of University of Port Harcourt Teaching Hospital, Port Harcourt, Nigeria: Why and when do newborns die? Niger J Paediatr 2008;35:75-81.  Back to cited text no. 1
    
2.Lawn JE, Zupan J, Begkoyian G, Knippenberg R. Maternal and neonatal conditions: Newborn survival. In: Jamison DT, Breman JG, Measham AR, Alleyne G, Cleason M, Evans DB, et al., editors. Disease Control Priorities in Developing Countries. 2 nd ed. New York: Oxford University Press; 2006. p. 531-50.   Back to cited text no. 2
    
3.Costello A, Francis V, Byrne A, Puddephatt C . Saving Newborn Lives: The state of the world's newborns. Washington DC 20036: Save the Children; 2001.  Back to cited text no. 3
    
4.Aziz K, Chadwick M, Downton G, Baker M, Andrews W. The development and implementation of a multidisciplinary neonatal resuscitation team in a Canadian perinatal centre. Resuscitation 2005;66:45-51.  Back to cited text no. 4
    
5.Houben CH, Curry JI. Current status of prenatal diagnosis, operative management and outcome of esophageal atresia/tracheo-esophageal fistula. Prenat Diagn 2008;28:667-75.  Back to cited text no. 5
    
6.Bickler SW, Kyambi J, Rode H. Pediatric surgery in sub-Saharan Africa. Pediatr Surg Int 2001;17:442-7.  Back to cited text no. 6
    
7.Ameh EA. Challenges of Neonatal surgery in Sub-saharan Africa. Afr J Paediatr Surg 2004;1:43-8.  Back to cited text no. 7
  Medknow Journal  
8.Shija JK. Neonatal surgical problems in Dar-es-Salaam, Tanzania. Med J Zambia 1977;11:139-43.  Back to cited text no. 8
    
9.Ameh EA, Ameh N. Providing safe surgery for neonates in sub-saharan Africa. Trop Doct 2003;33:145-7.  Back to cited text no. 9
    
10.Nwomeh BC, Mshelbwala PM. Pediatric surgical specialty: How relevant to Africa? Afr J Paediatr Surg 2004;1:36-42.  Back to cited text no. 10
  Medknow Journal  
11.Nandi B, Mungongo C, Lakhoo K. A comparison of neonatal surgical admissions between two linked surgical departments in Africa and Europe. Pediatr Surg Int 2008;24:939-42.  Back to cited text no. 11
    
12.White RD. Surgical emergencies In: Roberts KB, editor. Manual of clinical problems in Paediatrics. 5 th ed. Lippincott Williams and Wilkins Publishers; 2000. p. 275-81.  Back to cited text no. 12
    
13.Iroha EO, Egri-Okwaji MT, Odum CU, Anorlu RI, Oye-Adeniran B, Banjo AA. Perinatal outcome of obvious congenital malformation as seen at the Lagos University Teaching Hospital, Nigeria. Niger J Paediatr 2001;28:73-7.  Back to cited text no. 13
    
14.al-Gazali LI, Dawodu AH, Sabarinathan K, Varghese M. The profile of major congenital abnormalities in the United Arab Emirates (UAE) population. J Med Genet 1995;32:7-13.  Back to cited text no. 14
    
15.Nasir GA, Rahma S, Kadim AH. Neonatal intestinal obstruction. East Mediterr Health J 2000;6:187-93.  Back to cited text no. 15
    
16.Osifo OD, Ovueni ME. The prevalence, patterns, and causes of deaths of surgical neonates at two African referral pediatric surgical centers. Ann Pediatr Surg 2009;5:194-9.  Back to cited text no. 16
    
17.Ameh EA, Dogo PM, Nmadu PT. Emergency neonatal surgery in a developing country. Pediatr Surg Int 2001;17:448-51.  Back to cited text no. 17
    
18.Momoh JT. Exomphalos: Management problems in the tropics. Ann Trop Paediatr 1982;2:73-8.  Back to cited text no. 18
    
19.Adeyemi D. Neonatal intestinal obstruction in a developing tropical country: Patterns, problems, and prognosis. J Trop Pediatr 1989;35:66-70.  Back to cited text no. 19
    
20.Sowande OA, Ogundoyin OO, Adejuyigbe O. Pattern and factors affecting management outcome of neonatal emergency surgery in Ile-Ife, Nigeria. Surg Pract 2007;11:71-5.  Back to cited text no. 20
    
21.Narasimhan KL, Bhaskar V. Priorities in development of neonatal surgery in India. Indian Pediatr 2005;42:82-3.  Back to cited text no. 21
    

Top
Correspondence Address:
Rosemary O Ugwu
Department of Paediatrics and Child Health, University of Port Harcourt Teaching Hospital, Port Harcourt
Nigeria
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0189-6725.120886

Rights and Permissions



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]

This article has been cited by
1 Challenges of management and outcome of neonatal surgery in Africa: a systematic review
Sebastian O. Ekenze,Obinna V. Ajuzieogu,Benedict C. Nwomeh
Pediatric Surgery International. 2016; 32(3): 291
[Pubmed] | [DOI]
2 Associations with Perioperative Mortality Rate at a Major Referral Hospital in Rwanda
Jennifer L. Rickard,Georges Ntakiyiruta,Kathryn M. Chu
World Journal of Surgery. 2015;
[Pubmed] | [DOI]
3 The burden of waiting: DALYs accrued from delayed access to pediatric surgery in Kenya and Canada
Dan Poenaru,Julia Pemberton,Brian H. Cameron
Journal of Pediatric Surgery. 2015;
[Pubmed] | [DOI]



 

Top
 
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Email Alert *
    Add to My List *
* Registration required (free)  
 


    Abstract
   Introduction
   Patients and Methods
   Results
   Discussion
   Conclusions
   Acknowledgment
    References
    Article Tables

 Article Access Statistics
    Viewed3249    
    Printed90    
    Emailed1    
    PDF Downloaded303    
    Comments [Add]    
    Cited by others 3    

Recommend this journal