Geneva, Switzerland. A major humanitarian organization has performed close to 20,000 surgical procedures in resource-limited settings between 2001 and 2008 with an operative death rate of only 0.2 percent.

Of the 230 million major surgical procedures performed worldwide each year, an unknown number are performed in countries with marginal incomes, while an estimated 4 percent or less are done in poor-income countries. New findings suggests that surgical care can be provided safely in these circumstances with appropriate minimum standards and protocols.

The experiences of Médecins Sans Frontières (MSF: Doctors Without Borders) are reported in the Archives of Surgery. The fact that the poor-income countries "... bear the greatest burden of injury, violence and maternal mortality indicates a substantial unmet need for surgical care, although few data exist about the burden of unmet surgical disease in the developing world," the authors write.

In developed countries, surgical practices typically subscribe to quality control programs to monitor and improve safety that do not yet exist in resource-limited countries. Reportedly high rates of operative death in these nations have prompted a re-examination of the safety of international surgical care.

Kathryn M. Chu, M.D., M.P.H.
Assistant Professor
Colon and Rectal Surgery

Kathryn M. Chu, M.D., M.P.H., of Johns Hopkins Medical Institutions (Baltimore) and Médecins Sans Frontières (MSF: Johannesburg, South Africa) conducted a retrospective study of 17 MSF surgical programs from 13 countries. MSF is an international medical organization that provides surgical care in response to humanitarian crises.

Between 2001 and 2008, surgeons involved with MSF performed 19,643 procedures on 18,653 patients. Among these, 8,329 (42 percent) were emergency procedures, 7,933 (40 percent) were for obstetric-related problems and 2,767 (14 percent) were trauma-related. Eight of the 13 programs reported no deaths, the highest death rate was 0.9 percent and the overall death rate was 0.2 percent.

A higher rate of death was associated with programs in conflict settings, procedures performed under emergency conditions, complex procedures (including abdominal surgeries and hysterectomies) and those done in patients given a higher score under the American Society of Anesthesiologists classification of severity.

"As a large provider of surgical care in developing countries, assuring quality is paramount for MSF," the authors write.

"Our low operative mortality, even in a variety of emergencies, was partly the result of strict protocols for all essential aspects of surgical care."

"In most humanitarian contexts outcome data are difficult to collect, which means that structural and process indicators are even more important, as are minimum standards for essential items such as water, a blood bank, electricity, sterilization equipment and a postanesthesia care unit."

A wide range of additional organizations, including governments, non-governmental organization and missionary groups, provide surgical care in similar settings, the authors note. "Quality improvement programs are needed to regulate the enormous body of surgical providers in resource-limited settings," they conclude.

"In this respect, the World Health Organization (WHO) developed a checklist, Safe Surgery Saves Lives, as an important first step in a process of establishing global minimum standards in surgical care for humanitarian contexts."

"Operational research is needed to ensure such standardized approaches developed in relatively well-resourced settings are adapted to the complexities and constraints of humanitarian emergencies."

CitationOperative Mortality in Resource-Limited Settings: The Experience of Médecins Sans Frontières in 13 Countries. Kathryn M. Chu, Nathan Ford, and Miguel Trelles. Archives of Surgery 2010; 145(8): 721-725. doi:10.1001/archsurg.2010.137

Abstract

Objective. To determine operative mortality in surgical programs from resource-limited settings.

Design, Setting, and Participants. A retrospective cohort study of 17 surgical programs in 13 developing countries by 1 humanitarian organization, Médecins Sans Frontières, was performed between January 1, 2001, and December 31, 2008. Participants included patients undergoing surgical procedures.

Main Outcome Measure. Operative mortality. Determinants of mortality were modeled using logistic regression.

Results. Between 2001 and 2008, 19 643 procedures were performed on 18 653 patients. Among these, 8329 procedures (42%) were emergent; 7933 (40%) were for obstetric-related pathology procedures and 2767 (14%) were trauma related. Operative mortality was 0.2% (31 deaths) and was associated with programs in conflict settings (adjusted odds ratio [AOR] = 4.6; P = .001), procedures performed under emergency conditions (AOR = 20.1; P = .004), abdominal surgical procedures (AOR = 3.4; P = .003), hysterectomy (AOR = 12.3; P = .001), and American Society of Anesthesiologists classifications of 3 to 5 (AOR = 20.2; P < .001).

Conclusions. Surgical care can be provided safely in resource-limited settings with appropriate minimum standards and protocols. Studies on the burden of surgical disease in these populations are needed to improve service planning and delivery. Quality improvement programs are needed for the various stakeholders involved in surgical delivery in these settings.

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