Our Neonatal Surgery Experiences in Somalia.

Purpose: The aim of this study is to report surgical outcomes of the neonates who have undergone various surgical procedures. Materials and
Methods: In this retrospective study, 39 neonates who have undergone a surgical procedure in Mogadishu Somalia Turkey Recep Tayyip Erdoğan Training and Research Hospital, between October 2018 and March 2019 were included. Data regarding age, gender, diagnosis, surgical procedure, length of hospital stay, mortality, and cause of mortality were recorded.
Results: Of 39 neonates, 12 were female (30.7%) and 27 were male (69.3%). The mean age of the neonates at admission was 7.7 ± 7.6 days (1-30 days) days. The most common diagnoses were anal atresia (n = 12, 30.8%), esophageal atresia (n = 9, 23.1%), and pyloric stenosis (n = 5, 12.8%). The most common surgical procedures were colostomy creation (n = 10, 25.6%), esophageal anastomosis (n = 9, 20.5%), primary closure of anterior abdominal wall defects including bladder exstrophy (n = 6, 15.4%), and pyloromyotomy (n = 5, 12.8%). Mortality rate was 17.9%, and mortality causes were sepsis (n = 4, 57.1%) and congenital heart disease (n = 3, 42.9%). Neonates with the highest mortality by underlying primary surgical diagnosis were esophageal atresia (n=4, 57.1%).
Conclusion: The mortality rate from the surgical procedures of the neonates in Somalia is extremely high when compared with the developed countries. Employment of experienced pediatric surgeons and well-trained nurses, strict attention to the sanitary measures and shortening the time from birth to presentation might improve the surgical outcomes of the neonates in Somalia. Copyright:

INTRODUCTION

The immature anatomical, physiological, metabolic, and immunological functions and the stress caused by the postnatal conditions make the newborn vulnerable to various diseases.[1] Recent advances in neonatal care have led to great improvement in outcome of neonatal surgery in the Western world.[23] However, in underdeveloped countries such as Somalia, neonatal surgery continues to pose a challenge for health-care services. Delivery outside hospital, delayed referral, poor transportation, and lack of appropriate nursing staff and skilled physicians continue to contribute to the increased morbidity and mortality from neonatal surgery in developing countries.[4] As a consequence of insufficient antenatal care and the lack of the instruments required for intrauterine diagnosis, the expected outcome from neonatal surgery is still poor.[5] Studies on neonatal surgery in underdeveloped countries will reveal the deficiencies in this region and will guide the studies to be done to eliminate these deficiencies.

The aim of the present study was to provide data regarding the neonatal conditions requiring surgery and the outcome of the surgical procedures in a tertiary center in Mogadishu, Somalia. Population-based data on neonatal surgery in Somalia were found to be lacking in the literature. With this study, we hope to contribute to improving outcomes of the neonatal surgery and reducing of the neonatal mortality and morbidity.

MATERIALS AND METHODS

This study was conducted in Mogadishu Somalia Turkey Recep Tayyip Erdoğan Training and Research Hospital, retrospectively. In this study, 39 neonates who were admitted to the neonatal intensive care unit for surgery between October 2018 and March 2019 were included. Data regarding age, gender, main surgical diagnosis, surgical procedure, and length of hospital stay, mortality rate, and cause of mortality were recorded from the patient charts and institutional digital database.

This study was approved by the Institutional Ethical Committee and was carried out in accordance with the principles of the Declaration of Helsinki.

Descriptive statistical analyses were used. The data were given as mean ± standard deviation (minimum-maximum). The categorical variables were shown as number (n) and percentage (%). Statistical Package for the Social Sciences (SPSS) Windows software (version 22; IBM SPSS, Chicago, Illinois, USA) was used for all statistical analyses.

RESULTS

During this 6-month period, 226 patients were hospitalized in the neonatal intensive care unit. Of these, there were 39 neonates with a primary surgical diagnosis, 12 were female (30.7%) and 27 were male (69.3%). The mean age of the neonates at admission was 7.6 ± 8.3 days (1–30 days). Thirty-nine of 226 patients (17.3%) underwent surgical intervention for their underlying surgical condition [Table 1].

Table 1

Diagnoses of the neonates undergone surgical procedures

	n (%)
Anal atresia	12 (30.8)
Esophageal atresia	9 (23.1)
Pyloric stenosis	5 (12.8)
Ileal atresia	3 (7.7)
Omphalocele	3 (7.7)
Bladder exstrophy	2 (5.1)
Sacrococcygeal teratoma	2 (5.1)
Cloacal exstrophy	1 (2.6)
Duodenal atresia	1 (2.6)
Gastroschisis	1 (2.6)
Total	39 (100)

The three most common surgical diagnoses were anal atresia (30.8%), esophageal atresia (23.1%), and pyloric stenosis (12.8%).

The four most commonly applied surgical procedures were colostomy creation (25.6%), esophageal anastomosis (20.5%), primary closure of anterior abdominal wall defects including bladder exstrophy (15.4%), and pyloromyotomy (12.8%). Primary closure procedure was applied in patients with omphalocele (n = 3), gastroschisis (n = 1), and bladder exstrophy (n = 2). Table 2 shows surgical procedures applied to neonates.

Table 2

Surgical procedures applied to neonates

	n (%)
Colostomy creation	10 (25.6)
Esophageal anastomosis	9 (23.1)
Primary closure of abdominal wall defects	6 (15.4)
Pyloromyotomy	5 (12.8)
Ileal anastomosis	3 (7.7)
Anoplasty	2 (5.1)
Tumor excision	2 (5.1)
Duodenostomy	1 (2.6)
Ileostomy	1 (2.6)
Total	39 (100)

The mean length of hospital stay was 12.1 ± 8.5 days (3–40 days). Mortality rate was 17.9% (n = 7) and causes of mortality were sepsis in 57.1% (n = 4) and congenital heart disease in 42.9% (n = 3). Sepsis agents were coagulase-negative staphylococci (n = 2), Escherichia coli (n = 1), and Staphylococcus aureus (n = 1). Congenital heart diseases were ventricular septal defect (n = 1), patent ductus arteriosus (n = 1), and single ventricle (n = 1). The most common disease that results in death was esophageal atresia (57.1%). Table 3 shows the distribution of diseases that result in death by mortality causes. The mortality rate for all inpatients in the neonatal intensive care unit was 23% (n = 52).

Table 3

Primary surgical condition and associated comorbidity leading to death in our series

Diseases that result in death	Mortality causes
	Congenital heart disease, n (%)	Sepsis, n (%)	Total, n (%)
Duodenal atresia	0	1 (25.0)	1 (14.3)
Esophageal atresia	2 (66.7)	2 (50.0)	4 (57.1)
Ileal atresia	0	1 (25.0)	1 (14.3)
Omphalocele	1 (33.3)	0	1 (14.3)
Total	3	4	7

DISCUSSION

Neonatal surgical mortality in high-income countries has decreased to <5% in recent years.[67] However, little is known about the neonatal surgical cases in low- and middle-income countries including Sub-Saharan Africa (SSA).[8] Pediatric surgery is a novel surgical discipline for most of the SSA countries, except for South Africa.[9]

Previous data from Nigeria revealed that 6.2% to 8.9% of the neonates admitted to a newborn unit had a surgical condition.[410] In studies conducted in Nigeria and Tanzania, the burden of neonatal surgery in SSA was reported to be 20%–40%.[5] In this study, the rate of newborns who underwent surgical procedures among all inpatients in the neonatal intensive care unit was 17.3%. Substantial proportion of the indications for emergency surgery were intestinal obstruction, caused most commonly by anorectal malformation (44.2%). Exomphalos, intestinal atresia, and gastroschisis were the other frequent indications for emergency surgery.[1112] As a consequence of the shortage of the skilled pediatric surgeons and trained pediatric anesthesia personnel and the poor neonatal intensive care unit support, the morbidity and mortality are higher in SSA than high-income countries.[13] In studies conducted about SSA and African countries, were reported that common neonatal surgical conditions were intestinal atresia, abdominal wall defects, and anorectal malformations.[914] In a study conducted about African countries, it was reported that mortality was highest in emergency neonatal surgeries involving congenital diaphragmatic hernia, esophageal atresia, and ruptured omphalocele or gastroschisis. In addition, the overall average mortality rate was stated as 29.1% between 2005 and 2014.[14] In a study conducted in Nigeria, the most common cause of surgery was reported to be anorectal malformations. In addition, it was reported that mortality was 13.3%, and the most common cause of mortality was sepsis.[15]

Emergency surgery is the major contributor to the negative surgical outcomes, and mortality rates of 30% to 43% have been reported from different areas of SSA.[1617] In a study by Ameh et al. which enrolled 154 neonates from Nigeria, the authors reported that 66% of the recorded perioperative mortality was related to overwhelming infection, and 28% was associated with respiratory insufficiency.[17]

In this study, similar to the data derived from various parts of the SSA, congenital gastrointestinal system anomalies are the most frequent pathologies requiring surgery in neonates; the most frequent indications for emergency surgery were the anal and esophageal atresia. Accordingly, colostomy creation and esophageal anastomosis were the most frequently performed surgical procedures. The mortality rate was 17.9%, somewhat lower than the reported mortality rate in other parts of the SSA. Despite the poor local conditions in Somalia, compared to other countries of the SSA, having these operations performed by a pediatric surgeon in a tertiary center may have positively affected the mortality rate recorded in this study. Consistent with the published data which provided valuable information from different areas of the SSA, sepsis was the leading cause of deaths (n = 4, 57.1%).

One of the limitations of our study is that the number of patients is relatively low. The second is that the study is single centered. Multicenter studies with more patients can provide more valuable results.

CONCLUSION

In this study, the results of newborns who reached our hospital in Somalia and underwent surgical treatment are presented for the first time. The mortality rate from the surgical procedures of the neonates in Somalia is extremely high when compared with the developed countries. Employment of experienced pediatric surgeons and well-trained nurses, strict attention to the sanitary measures and shortening the time from birth to presentation might improve the surgical outcomes of the neonates in Somalia.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.