Mortality and Its Associated Factors of Bowel Obstruction after Surgical Treatment Among Adult Patients at Debre Markos Comprehensive Specialized Hospital, Northwest Ethiopia 2021 (Retrospective Cross-Sectional Study)

Background: - Bowel obstruction is a mechanical or functional obstruction of bowel that prevents the normal movements of products of digestions. Even if Treatment outcome of bowel obstruction varies from area to area, time to time, and also increasing age is signicant factor of treatment outcomes of bowel obstruction. Outcome of bowel obstruction and associated factors on adults have been poorly explored in the previous Ethiopian study particularly in the study area. Objective: To assess prevalence and its associated factors of mortality after surgical treatment of bowel obstruction among adult patients at Debre Markos comprehensive specialized hospital, Northwest Ethiopia 2021 Methodology: - Institution based Cross sectional study design was used. A total 517 study participates was included by using consecutive sampling techniques from 23/02/2017 to 23/02/2021 at Debre Markos Comprehensive specialized Hospital. Data was collected from patient registration books and medical records available in the hospital by using checklists. Then data were entered to Epi data version 4.1 and exported to SPSS version 25 for analysis. A binary logistic regression model was tted to identify factors associated with treatment outcome of bowel obstruction. P value less than 0.05 considered as signicant in multivariable analysis ;95% Conclusion: Mortality after surgical treatment of bowel obstruction were high and having gangrenous bowel, low hemoglobin level, late presentation, post-operative complications, leukocytosis and comorbidity was independent predicator of unfavorable outcomes. Give special care for patients treated with low hemoglobin, late presentation, having complications and leucocytosis. Create awareness to the public on advantage of early presentation to hospital.

Since BO mostly treats through surgery in emergency. It causes to complications after post operation, such as surgical site infection, septic shock, and pneumonia postoperatively [19]. Management of bowel obstruction depends largely upon early diagnosis, skillful treatment and managing the pathological effects of the obstruction. Clinical, radiological and operative ndings put together can diagnose the obstruction of bowel. The morbidity and mortality rates regarding to bowel obstruction have decrease results from the introduction of new advanced diagnostic tests, uid and electrolyte correction, more effective antimicrobials and surgical treatment, but the condition still remains a challenging surgical diagnosis. Resection, anastomosis intussusceptions milking, Hartman's, hernia repair, volvulus Derotation and Mekels diverticulectomy were producers to treat bowel obstruction [3,7,21].
Bowel obstruction remains common surgical emergency in the surgical eld worldwide. It was the main cause of surgical emergency which cause to high risk of mortality and morbidity in African. Despite advance surgical treatment of bowel obstruction magnitude of unfavorable treatment outcome of BO in Africa was high [23,24]. In Ethiopia bowel obstruction is highly prevalent which cause to surgical emergency secondary to appendicitis and magnitude of mortality of bowel obstruction is high and still has a great problem nationally [25][26][27][28].
There are risk factors which contributes to mortality for patients who have BO and treated surgically like age, sex, duration of illness before treatment, length of hospital stay, co morbidity, procedure performed and intra operative nding [8,26,34,39]. Even though morbidity and mortality due to bowel obstruction had different factors in the previous studies poorly explored [8]. It is worse in developing countries which lack health care facility, lack health care seeking behavior, these more serious the outcomes related to such like patients who present lately to hospital and cause to mortality. Even if increase medical services and have advance health professionals those who are well familiar with BO pathophysiology, increase infection prevention practice, and access of materials important for early diagnosis of bowel obstruction the problem is continue high. Littlie studies done in our country Ethiopia based on bowel obstruction treatment outcome on adult individuals even if its signi cantly associated with increased age [35].
Mortality after surgical treatment of bowel obstruction varies from area to area, change from time to time, and also age is signi cant factor for mortality due to bowel obstruction, it needs recurrent studies for the treatment outcome of bowel obstruction. Moreover variable which was not studied pervious included in this study. There are no publishing studies in the study area of northwest Ethiopia at Debre Markos comprehensive specialized hospital. So the main purpose of these studies is to full ll this gap and recommend accordingly through assessing mortality patients due to bowel obstruction and its associated factor. Sample size determination and sampling procedure All patients, who had operative management for bowel obstruction and admitted at Debre Markos comprehensive specialized hospital from September 11 /2018 to March 9 /2019, were included in the study. However, patients with acute appendicitis who had incomplete data record over the variable of interest were excluded from the study. The sample size were determined by census sampling method, in which all acute appendicitis cases operated in Debre Markos referral hospital from September 11/2018 to March 9/2019 were included in the study giving a total sample size of 169 patients.

Data Collection
Data were collect from patient registration books and medical records available in the hospital through checklists adapted from previous studies [36,62]. Two professional data collectors and one supervisor were recruited, who were BSc nurses. They were also received training on how to collect data to ensure common understanding of data collection process. First medical record numbers for all the patients with BO in the study period were identify from registration logbooks then their charts were bring out from the card o ce and those tools including socio-demographic characteristics, clinical manifestation, mortality, causes of obstruction, type of bowel obstruction, length of hospital stay, complications, intra operative procedures, intra operative ndings and co morbidity, patients preoperative pro le and other relevant clinical variables related to the disease was reviewed.

Statistical analysis
The collected data was coded and entered using Epi-Data Version 4.2. Then, it was exported to SPSS Version 25 statistical software for further analyses. Descriptive statistics for continuous variables was presented using median and range. Additionally, descriptive summaries for categorical variables were presented using tables, gures, and charts. The presence of outliers and multicollinearity among independent variable was check by Variance in ation factor which was less than 3. Both bivariable and multivariable binary logistic regression models were tted. Variables with p-values <0.25 in the Bivariable analysis was entered to the multivariable analysis.
Model goodness of t was checked in Hosmer-Lemeshow goodness-of-t at (p=0.86). Variables with p-values < 0.05 in multivariable regression were considered as statistically signi cant factors of the unfavorable treatment outcome of bowel obstruction. The adjusted odds ratio with its 95% CI was reported in the nal binary logistic regression table.

Operational De nition
Mortality -Death of patients after surgical treatment of bowel obstruction [34].
Length of hospital stay Number of days elapsed while the patient is in the hospital from admission time to discharge or death, if more than 7 day considered as prolonged [34] Incomplete chart patient's record which had not incorporated variables of interest [59] Ethics The study was carried out after getting approval from Debre Markos University College of health science post graduate research and ethical review committee. Staffs at surgical ward, Card room, and operation room were informed about the aim of the study and verbal consent was taken for the reason to use patient cards and registration books. Con dentiality of the patient's information was assured and the information was recorded in secret. The procedures were in compliance with Helsinki Declaration.

Socio-demographic characteristics
In this study 517 respondents were included and response rate of 100%, among those 413(79.9%) and 104(20.1%) were males and female. Age group from 15-24 was 17.4%, 25-34 accounts 18%, 35-44 accounts 17%, and 25% of the respondents were in the age group (>= 55) the median age of the participants was 45 ± 26 (IQR) ( Table 1). Sign And Symptoms Of Bowel Obstruction All patients 517(100%) complain abdominal pain followed by abdominal distention and vomiting ( gure1) Cause BO and types of procedure performed As shown in this study volvulus was the main cause of bowel obstruction, 37.2% of SBO was cause due to volvulus and LBO caused by sigmoid volvulus was 36% followed by adhesion, hernia and intussusceptions.
As ndings of this study De-rotation of bowel was the main procedure to treat bowel obstruction surgically which accounts 39.8% followed by anastomosis and resection of bowel (39.3). Patients treat through anastomosis and resection accounts 72.9% from the total of 70 died patients ( guer3).

Mortality, postoperative diagnosis and complication of BO
The ndings of these studies shows 13.5% of the respondent was died after surgical treatment of bowel obstruction and 86.5% was discharge with improvement. SBO accounts 60.5% and LBO 39.5% of bowel obstruction. There were 0.6% preoperative and post-operative diagnosis discrepancies. 3 patients in the preoperative diagnosis was SBO but postoperatively diagnosed as LBO and the discharge alive with improvement. From total participants 24.8% patients develop post-operative complications like SSI, wound dehiscence, pneumonia and sepsis (Table2).  It is high compared to studies in Chiro general hospital 3.9% [26]. The difference might be due to socio-demographic characteristics of the population only 11% of the population study >=55 years in Chiro general hospital where as in this study 27.1% of patients age was >=55 years old and types of procedure done in this study anastomosis and resection of bowel was signi cantly associated with death but not in Chiro general hospital. It is low compared with studies in in Barcelona Spain 18.8% [44] and Malawi 18.6% [46]. The possible reason of the difference might be due to sociodemographic characteristics of the participants, the mean age of patients in this study was 43.8 but 67.47 at Spain which was signi cantly associated with mortality and in this study patients treated in referral hospital but in Malawi patients treated at district hospital which has low infrastructures.
There are various factors responsible for mortality after patients treated surgically for bowel obstruction. The sociodemographic characteristic that was signi cantly associated with treatment outcomes of BO was age. Old age( >=55 )was signi cantly affect bowel obstruction treatment outcome nearly 3.7 times more likely unfavorable outcome than those with age group (15)(16)(17)(18)(19)(20)(21)(22)(23)(24) at p value 0.046. This is in line with similar studies in turkey[8], India [39], Bangladesh [54], and Chiro referral hospital [26] respectively. The possible reason may be due to advance age is risk for postoperative complication and death [63] In this study intraoperative nding was signi cantly associated with treatment outcomes of bowel obstruction. Gangrenous bowel signi cantly associated with unfavorable outcomes of bowel obstruction. This is in line with studies in Kenya [23], Nigeria [19], Chiro[26] and Adama [59]. but it is contradict studies in Gondar University [47]. The difference might be due to in this study 37.9% of Patients present to hospital late which accounts 55.7%(39) death from the total 70 deaths. Post-operative complication was highly signi cant association with treatment outcomes of bowel obstruction. Patients who developed postoperative complication cause to unfavorable outcomes than those not yet develop postoperative complications which are supported by studies at Atthat Chatolic Hospital [34]. The possible reason for postoperative complication might be due to abdominal surgery by its nature cause to complications like surgical site infection, bowel obstruction surgery is mostly done as emergency and also old ages is risk factor for postoperative complications and death [63,64]. Preoperative complication also leads to unfavorable outcomes of bowel obstruction which is consistent with studies at Jimma [36].
The nding of this study showed that late presentation of patients to hospital was signi cantly associated with poor treatment outcomes of bowel obstruction. Patients present after 24 hours of disease onset more likely had poor outcome than those who present within 24 hours of disease onset. This in line with studies in D.Y.Patil Hospital, Navi Mumbai [3], turkey[8], India [39],Tanzania [51], Lady Curzon Hospital India [65], and Nigeria [19]. These cause to bowel damage and post-operative complications. The possible reason may be low health seeking behavior and transport problem, since most of the individuals comes from rural area. To improve this creates awareness for the public for advantages of early presentation to hospital and surgical treatment.
Length of hospital stays also highly signi cant association with bowel obstruction treatment outcome. Patients admitted more than 7 days in the hospital cause to poor outcomes which is supported by studies conducted in Kenya [23] and Adama [59]. This might be due to Long period of hospital stay lead to hospital acquired infection. In this study 24.8% of the respondents develop post operation complications and 21.1% had comorbidity both of this cause to prolonged hospital stay and associated with mortality after and during bowel obstruction treated surgically[66, 67]. WBC signi cantly associated with treatment outcomes of bowel obstruction. Patients those who had leukocytosis signi cantly associated with poor treatment outcomes of bowel obstruction. This is in line with studies in turkey [55]. Comorbidity signi cantly affects treatment outcomes of bowel obstruction negatively which is supported by studies in Turkey[8]. The possible reason might be due to mostly comorbidity occur in aged groups [68] and in this study 25% of the respondent was (>=55) years old and those were signi cantly associated with mortality. Aggressive evaluation of comorbidities as much as possible is important to improve postoperative outcomes [69]. Hemoglobin was signi cantly associated with treatment outcomes of bowel obstruction. Having low hemoglobin was signi cantly associated with poor treatment outcomes of bowel obstruction.

Conclusion
Based on the nding of these study poor treatment outcomes of bowel obstruction that was treated surgically at DMCSH was high. Having intraoperative ndings of gangrenous bowel, long period of hospital stay, old age, pre-operative complications, postoperative complications, low hemoglobin, leukocytosis and late presentation to hospital were found independent predicator of unfavorable outcomes. Appropriate preoperative, intra and post-operative management, high quality surgical intervention and sound clinical judgment can be reduce risk of death. Create awareness to the population for clinical presentation, advantage of early presentation to hospital this important to early detection of disease and providing early surgical interventions. Providing special care should be consider for those patients in old aged group to reduce mortality.

Limitation of the study
It was impossible to measure some essential parameters, which may signi cantly contribute for outcomes of BO like Educational status of the patients, Occupational status, and House hold income per month since secondary data was utilize in this study. The results of the study may not show the actual picture of the problem in the community since this study was institutional based study. Figure 1 Sign and symptoms of bowel obstruction among patients admitted in surgical ward at Debre Markos Comprehensive specialized hospital North west Ethiopia 2021(n=517) Figure 2 causes and death of bowel obstruction among patients admitted in surgical ward at DMCSH North West Ethiopia 2021(n=517)