Outcome and current practice of emergency laparotomies at the Colonial War Memorial hospital, Fiji: a prospective observational study
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Keywords
access to care, emergency laparotomy, global surgery, NELA, Pacific health, Perioperative mortality
Abstract
Introduction: Emergency laparotomy (EL) for gastrointestinal conditions carries high and variable mortality and has become a focus of national audits and quality-improvement programmes. There are no published data describing EL outcomes or adherence to standards of care in Fiji or the wider Pacific region. This study describes patient characteristics, adherence to international standards of care, and 30-day in-hospital mortality among patients undergoing gastrointestinal EL at Colonial War Memorial Hospital (CWMH) in Suva, Fiji.
Methods: A single-centre, prospective observational study of adults (>18 years) undergoing EL for gastrointestinal pathology at CWMH between December 2023 and May 2024 was conducted. Data were collected using the National Emergency Laparotomy Audit (NELA)-based pro forma. The primary outcome was all-cause in-hospital 30-day mortality. Secondary outcomes included patient demographics, preoperative risk profiles (American Society of Anaesthesiologists (ASA) physical status classification and NELA-predicted mortality) and adherence to six key NELA standards of care.
Findings: Forty-six patients were included. Median age was 56 years (IQR 49–64) with equal sex distribution; 33/46 (72%) were iTaukei (Indigenous Fijians). ASA was recorded for 44 patients, of whom 38/44 (86%) were ASA class III–V; 21/46 (46%) had a NELA predicted 30-day mortality of >10%. Common indications were bowel obstruction and perforation. Preoperative CT was performed in 37/46 (80%) cases, while a consultant radiologist report was available in 1/46 (2%). Preoperative risk assessment was documented in 18/46 (39%). Both consultant surgeons and anaesthetists were present in 9/34 (26%) high-risk cases; and timely theatre access was achieved in 14/25 (56%) eligible cases. The 30-day in-hospital mortality was 35% (16/46; 95% CI 23% to 49%). Observed mortality exceeded predicted mortality across all NELA risk groups.
Interpretation: EL at CWMH is associated with substantially higher mortality than international benchmarks, alongside low adherence to several perioperative standards. Although patient risk profiles were high, the consistently elevated mortality across all risk strata suggests that deficiencies in perioperative processes of care may also have contributed to adverse outcomes. Context appropriate, NELA standards including routine risk documentation, consultant involvement, timely theatre access and prioritised critical care, should be implemented and prospectively evaluated.
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