Prevalence and factors associated with re-laparotomy among patients operated in Debre-Markos Referral Hospital, North West Ethiopia: Retrospective cross-sectional study

Background Re-laparotomy is one of the causes of morbidity and mortality among patients with abdominal surgery; unless efforts are made to prevent in advance by identifying the potential risk factors. Methods Retrospective cross-sectional study was conducted at Debre-Markos Referral Hospital from three hundred and ninety charts (390) from January 1, 2015, to January 30, 2017. Data were analyzed using Statistical Package for Social Science (SPSS) version 22. The associated factors for re-laparotomy were identied using multivariable logistic regression. P-value < 0.05 was considered to be statistically signicant. Results We studied 390 patients based on charts. Two hundred seventy-four patients (70.3%) were males. Forty-eight patients (12.3%) performed re-laparotomy. Patients with the duration of operating on initial surgery >60 hrs, AOR=3.30(95%CI [1.40-7.41, p=0.05]), diabetes mellitus, AOR=4.79(95%CI [1.55-14.80, p=0.007]), elective surgery, AOR=0.17(95%CI [0.05-0.56, p= 0.004]) Conclusion Even re-laparotomy is preventive; it is found to be in-patients underwent abdominal surgery. Therefore, appropriate preventive intervention to be taken to change those factors of the rst surgery.

Re-laparotomy occurs once or more than once related to complications (8).It is one of the causes of morbidity and mortality among patients with abdominal surgery (1,9); unless efforts are made to prevent in advance by identifying the potential risk factors.The most common indications for relaparotomy are peritonitis, infection, bleeding, abscess, anastomotic leakage, wound dehiscence, necrotizing pancreatitis, bowel necrosis, bowel obstruction and evisceration (10,11).This study concluded that patients with re-laparotomy had high in mortality as well as exposed to the disease (10,11).Research, however, lacks in examining the effect of re-laparotomy on abdominal surgical patients.It suggested that patients with re-laparotomy are at higher risk of morbidity and mortality (2).This higher often attributed to treatment of complications take a long time, which creates a psychological and economic burden of those who are undergoing repeated abdominal surgery related to the first abdominal surgery of mortality (12).Repeated abdominal surgery can induce the patient a poorer immunity resistance (13), which may influence postoperative outcomes.Even Preoperative and postoperative antibiotic, counting of the instruments, instrumental processing and wound care (14) used as a preventive approach; problems of health system service, patient factors (15), and comorbidity (9) may be underlying factors leading to poorer outcomes after first surgery.Although it is preventable, it is still one of the problems after first surgery.Most of the problems occur to individual particularly general surgery (16).
Re-laparotomy is one of the conditions associated with providing inappropriate health services at first surgery for which prevention is possible with proper intervention (3,13,(17)(18)(19).In an individual with abdominal surgery, the presence of re-laparotomy may affect in many ways.It contributes to lengthening the hospital stay, then to the high chance of mortality (12,13).Most individuals with reabdominal opening worldwide are urgently or latently develop complications, mortality rate considerably high (2).
The management of people with re-laparotomy is challenging because of more complications leads the client to multi-organ failure (1,9,13,18).I think patients and health workers need positive outcome of first surgery.However, re-laparotomy occurred in the different part of the world.Information on the magnitude and associated factors of re-laparotomy is necessary to focus attention on minimizing the problem.Although the re-laparotomy expected in abdominal surgery, there is lack of evidence showing the magnitude of the problem and associated factors in Ethiopia.
Therefore, to offer baseline information and highlight magnitude of the problem, the current study was proposed to assess the prevalence and factors associated with re-laparotomy in Debre-Markos Referral Hospital.

The study design and setup
A retrospective cross-sectional study conducted at Debre-Markos Referral Hospital.Debre-Markos is 300 km from the capital city Addis Ababa.The hospital established was in 1964 and provide outpatient and inpatient services for more than 3.5 million peoples living in its catchment area.

Source population
All patients treated with laparotomy surgery in Debre-Markos Referral Hospital were source population.

Study population
Records of all patients that undergo laparotomy in Debre-Markos Referral Hospital from January 1, 2015, to January 30, 2017, were study population.

Sample size determination
The sample size determined by using single population proportion formula for the assumption of 50 % proportions, 95 % confidence level, and 5 % margin of error.The total sample size was 384 charts.By assuming a 10% non-response rate, the last sample size determined as 422.

Sampling technique
Simple random sampling methods were applied for the choice of charts from 875 abdominal surgeries in general surgery by using the patient's medical registration number (MRN) following open EPI version 3.

Data collection and rules
After pretest was conducted 5% of charts from University of Gondar Referral Hospital, then real data was collected from Debre-Markos Referral Hospital.Primarily total two years laparotomy from January 2015 to January 2017 was counted.The list of patients with laparotomy procedure selected from the record books in the operating room.Followed by, medical registration numbered (MRN) of everyone recorded and then open EPI version 3 applied to 422 charts.By using card numbers, charts of the patient retrieved from the card room for collect variables.

Independent variables
Age, Sex, operating room (OR) latency, type of procedure, urgency of surgery, Site of surgery, hypertension (HTN) , diabetes mellitus (DM) , hepatic malignancy, Chronic Obstructive Pulmonary Disease (COPD), Ischemia, peripheral vascular disease, jaundice >3 months, end stage of renal disease, Stricture behavior at diagnosis were independent variables.

Re-laparotomy
It is re-operation of the abdominal surgery site associated with the first surgery within 60 days.

Stricture behavior at diagnosis
It is inflammatory bowel diseases, which involves small bowel stricture, colonic stricture and lead to significant complications.

Index surgery
It is the first time for the abdominal surgery.

Urgency
Elective or emergency conditions condition of the surgery.

Surgery site
It is the site the surgical procedure.

Data processing and analysis
Data were coded and cleaned using EPI INFO version 7statistical software and exported to SPSS version 22 for analysis.Descriptive statistics were used to present socio-demographic, surgical interventions and co-morbidities.Percentages, frequencies, and cross tabulation were used to describe patient characteristics and surgical characteristics.Bi-variable and multivariable logistic regression model was used to identify associated factors of re-laparotomy.The finding was presented using unadjusted and adjusted odds ratios and their 95 % Confidence Intervals.The p-Value of less than 0.05 considered as statistically significant in multivariable analysis.

Ethical considerations
Ethical clearance obtained from the University of Gondar, College of Medicine and Health Science Ethical review board.A formal letter of cooperation was written to Debre-Markos Referral Hospital and obtained permission from Hospital management before starting data collection.After the purpose and aim of the study had informed, verbal consent obtained from the chart room workers.Data were kept anonymously in the distributed data extraction format to keep confidentiality.

Socio-demographic characteristics of participants
A total of 422 charts retrieved for study.Among these, 116 (29.7%) were females, and 274(70.3%)were males with the age range of 7years to 75 years.Of the 422 charts, 390(92%) charts were found complete.Among 390 charts, re-laparotomy identified from 48 patients with the prevalence of 12.3%.

Prevalence of re-laparotomy relation to features surgical intervention on patients operated in general surgery.
Lower gastrointestinal system surgeries such as colon 25(6.4%), and appendix 14(3.6%) was leading procedure followed by gallbladder 2(0.5%) (Table 2).

Factors associated with re-laparotomy
On bi-variable logistic regression model, six variables; such as latency of first surgery >60 hr, elective surgery, IEOS professionals, DM, HTN, and COPD were associated with re-laparotomy at p < 0.25.
The latency of surgery greater than 60hr, elective surgery and DM were independently associated factors of re-laparotomy in multi-variable regression analysis.
Multivariable logistic regression analysis revealed patients with the duration of operating on initial surgery >60 hrs were 3.3 times more likely to develop re-laparotomy compared with patients underwent first abdominal surgery within <60 hrs of the illness, AOR=3.30(95%CI[1.40-7.41]).

Discussion
Out of 390 patients who underwent laparotomy procedure, 48 patients performed re-laparotomy which gives the overall prevalence of 12.3%.The finding was similar to studies done in USA 15% (3).
The finding also supported by a study conducted in India 18.5% (21).But, our finding was higher than compared to the study done in Zambia 3.3% (5).The discrepancy might be due to the inclusion of gynecological and obstetric surgery in those studies while only general surgery included in our study.
Another discrepancy might be due to less study period, one year study period only conducted in those study while two year's study period in our study.But the finding was lower compared with the study conducted at Netherlands 27 % (22).The studies done in the Netherlands included only emergency surgery but in our study, both emergency and elective surgeries included, this might be due to the reason why those studies find out high prevalence of re-laparotomy compared to our study.
The present study revealed that patients OR latency in >60hrs were 3.3 times more likely develop relaparotomy compared with patients operated in <60hrs with AOR=3.30(95%CI[1.40-7.41,P-value=0.05]).The study was in agreement with other studies (17) confirming that as the duration of illness goes up the risk occurrence of re-laparotomy increases.Authors revealed that severity of illness increases to develop re-laparotomy due to perforation or generalized peritonitis (23).
We found that patients with elective surgery about 83% times less likely to develop re-abdominal operation compared with patients who conducted emergency surgery with AOR=0.17(95%CI[0.05-0.56,P-value=0.004]).This finding was in line with other studies done in Korea (6).
Authors revealed that, in elective surgery, there is time to plan and optimize the patient before the operation but in the emergency, it is striking (7).
In the present study, patients who had the history of DM were 4.8 times more likely to develop relaparotomy, AOR=4.79 (95%CI [1.55-14.80,P-value=0.007])compared with patients who had no history of DM which is in line with another study (24), this might be due to the high level of blood sugar which makes a comfortable condition for the multiplication of micro-organisms and makes reopen of abdominal surgery.

Conclusions
The overall prevalence of re-laparotomy was 12.3% which was higher compared with the report from some developing countries like Tanzania and lower compared to developed countries.OR latency in >60hrs, emergency surgery and DM were associated factors for re-laparotomy.Examining and identifying high-risk patients and accordingly taking all appropriate care should be done to decrease the risk of re-laparotomy.Shortening the preoperative hospital stay and duration operation further decrease the prevalence of re-laparotomy.Further researches with long study period and with large sample size should be done to get overall associated factors of re-laparotomy.

Ethical considerations
The ethical clearance was obtained from the ethical review committee of the department of surgical nursing on behalf of the Institutional Review Board of the University of Gondar.Permission letter was obtained from debermarkos town healthy office administration.Furthermore, after a thorough discussion and explanations of the purpose, benefit and the possible risks of the study, oral informed consent was obtained from each study participants.Women aged below 18 years would have allowed participating in the study considering that they are emancipated minors.The study participant's confidentiality was maintained by avoiding possible identifiers, such as the name of the client, and using only numerical identification.
Health Sciences at the University of AD has Bachelor of Science Degree in Nursing, MSc in Emergency and Critical Nursing.

Declaration
This declaration statement is to verify that all authors have agreed on the manuscript to being submitted and no any disagreement of concern to declaring.We confirm that; the article is the original work of authors, and the data that support the findings of this study are available from the corresponding author.We affirm that the article has not received earlier publication and is not under consideration for publication elsewhere.We have ensured that the submission made here, including the main paper, database entries, and software code, does not contain any plagiarized material.We attest to the fact that all authors listed here have contributed notably to the effort, have read the manuscript, attest to the validity and legitimacy of the data and its interpretation, and agree to its submission of the BioMed central nursing journal.
All authors agree that author list is correct in its content and order and that no revision of the author listed made without the official approval of the Managing Editor.No other authors will be added post submission unless editors receive the agreement to all authors and detailed information supplied about to why the author list should be amended.We agree to follow the formalities as given on the website of the journal.
As the corresponding author, I also declare that this work supported by the University of Gondar, Ethiopia.
I am submitting this on behalf of all authors.
that have helped us in selecting charts until bringing to an end the work.We would like to express our gratefulness to the staff of Nursing, for their help in searching relevant references and helping us during our work.Finally, we would like to express our gratitude in advance to the department of nursing at Gondar University for providing the opportunity to do this research.
AbbreviationsCOPD Chronic Obstructive Pulmonary Disease DM Diabetic Mellitus GIS Gastro-Intestinal System HPB Hepatic-Pancreatic-Biliary HTN Hypertension IEOS Integrated Emergency obstetrics and Surgery MRN Medical Registration Number OR Operating Room Table4.Bivariable and Multivariable regression analysis of factors associated with re-laparotomy among patients operated at Debre-Markos referral hospital, Debre-Markos, Northwest Ethiopia, Table2.Frequency distribution of re-laparotomy in relation to features on surgical interventions in surgical patients at Debre-Markos Referral Hospital from January 1, 2015, to January 30, 2017.