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Observations

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Expertise and supplies make many surgeries very safe in the developing world

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doctors perform surgery in africaA new analysis of surgeries completed in developing countries revealed a surgical mortality rate of just 0.2 percent, suggesting that when well-trained and outfitted staff are available, surgery can be quite safe in areas of violent conflict, such as Southern Sudan.


The study, published online August 16 in Archives of Surgery, assessed 19,643 surgical procedures completed between 2001 and 2008 by staffers and others involved in Médecins Sans Frontières (Doctors Without Borders) programs in Burundi, Central African Republic, Chad, Democratic Republic of the Congo, Haiti, Indonesia, Ivory Coast, Mali, Niger, Pakistan, Sierra Leone, Somalia and Southern Sudan. Those operations resulted in just 31 deaths, according to the organization, members of which performed the analysis.


Previous work has put surgery-linked deaths as high as 10 percent in parts of Africa. The statistical disparity is likely due in part to variable levels of care—and of reporting.


"There is a paucity of data on the safety of surgical programs and resource-limited settings, mostly due to a lack of resources to collect data or a centralized database," noted the researchers, led by Kathryn Chu, of Johns Hopkins Medical Institutions and Médecins Sans Frontières.


All of the procedures in the study were completed with at least some professional surgical help in settings equipped with anesthetics, antibiotics, blood banks, clean water, electricity, operating rooms, painkillers, post-op and post-anesthesia care and sterilization units.


The operations were also, to some extent, self-selecting, as the site needed to have both the requisite expertise and equipment on hand to undertake the procedure, according to the researchers. Thus, the surgeries in the assessment don't "accurately reflect the burden of surgical disease for our catchment populations," the authors noted. "We believe that the unmet burden of surgical disease in these communities is large."


Only some five percent of needed surgery is performed in developing countries, Thomas McIntyre and Michael Zenilman, both of State University of New York Downstate Medical Center's Department of Surgery, noted in a commentary piece published in the same issue of Archives of Surgery. And about four percent of the world's 320 million operations each year are done in poor countries. "As a result, rates of maternal mortality are high, minor surgical pathologies become lethal, and treatable trauma progresses to death," McIntyre and Zenilman wrote.


The highest rates of surgical deaths in the study were those in conflict settings (about 0.9 percent), though the most frequent procedures there—and elsewhere—were obstetric, rather than trauma-related. "Undoubtedly, violent trauma increases in these settings, but in many contexts, the prevention of maternal and neonatal mortality remains the most important reason for emergency surgery," Chu and her colleagues noted.


The mortality rates cover only those deaths that occurred during surgery, as neither in-hospital nor post-release deaths were recorded in these records, thus the overall mortality rate due to surgical procedures in these areas might be higher.


"Nevertheless," the researchers concluded, "more than 19,000 procedures were preformed with extremely low operative mortality, demonstrating that surgical care is feasible in resource-limited settings."


Image courtesy of iStockphoto/veronicadana

The views expressed are those of the author and are not necessarily those of Scientific American.

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