Outcomes and Its Associated Factors among Patients with Abdominal Trauma Requiring Laparotomy at Asella Referral and Teaching Hospital, South Central Ethiopia: A Retrospective Cross-Sectional Study

Trauma is a serious public health problem, and abdominal injuries are among the leading causes of hospitalization after trauma. Therefore, this study aimed to determine the outcome of abdominal trauma and its predictors in patients who underwent laparotomy at Asella Referral and Teaching Hospital (ARTH), South Central Ethiopia. We conducted a retrospective institutional based cross-sectional study of patients who underwent laparotomy for abdominal trauma at ARTH from October 1, 2015, to September 30, 2020. Bivariate and multivariate logistic regressions were used to determine associations between independent factors and mortality due to abdominal trauma, and a P value of <0.05 indicated statistical significance. Out of 139 patients, 110 (79.1%) were males and 88 (63.3%) aged <30 years old, with a mean age of 29 ± 15.73 years. The most common mechanism of injury was penetrating trauma, which accounted for 94 (67.6%) patients. The mortality rate was 21 (15.1%). Factors such as blunt mechanism of injury (95% CI: AOR: 3.36, 1.24–9.09), SBP < 90 mmHg at presentation (95% CI: AOR = 9.37, 3.28–26.80), time >6 hours from trauma to admission (95% CI: AOR: 5.44, 1.78–16.63), unstable intraoperative patient condition (95% CI: AOR = 8.82, 3.05–25.52), and patients who need blood transfusion (95% CI: AOR: 6.63, 1.92–22.91) were significantly associated with mortality. The mortality rate of abdominal trauma patients who underwent laparotomy was high. Therefore, healthcare providers should provide priority for traumatic patients as prolonged waiting time to get healthcare results in poor outcomes for the patients.


Introduction
Trauma is a health problem associated with physical injury and is the third leading cause of disability worldwide [1].Globally, approximately fve million people die annually from injuries, with around 90% of deaths occurring in low-and middle-income countries (LMICs) including Ethiopia [2,3].Globally, the abdomen is one of the most frequently injured areas in trauma patients which accounts for 25% of all traumatic events [4][5][6].In Ethiopia, abdominal trauma is a health problem and accounts for approximately 9-14% of all trauma admissions and is the third cause of emergency laparotomy [3].Abdominal injuries can be classifed as blunt or penetrating, usually involving organs such as the spleen, intestines, stomach, liver, diaphragm, and kidneys [7,8].Te majority of abdominal injuries are caused by blunt trauma secondary to Road Trafc Accident(RTA), while stab wounds and gunshot wounds are the most common types of penetrating injuries [9][10][11][12][13].In most cases, penetrating abdominal injuries can be easily and reliably diagnosed, while blunt injury mechanisms can often be overlooked because clinical signs and symptoms are less obvious [13].Tus, management of these injuries requires careful triage for appropriate intervention, although 25% of patients with abdominal trauma require surgery.Te most common indication for laparotomy was hemodynamic instability or ongoing blood loss [14,15].Although abdominal trauma is a common indication for surgery, outcomes and complications after surgery vary from health facility to health facility.Previous epidemiological studies showed that postoperative complication rates range from 18% to 42%, while mortality ranges from 8.5% to 13% [7,10,11].Sociodemographic factors, mechanism of injury, the presence of associated extraabdominal injuries, admission systolic blood pressure, time to injury to admission, length of hospital stay (LOS), anemia, and postoperative complications were reported to signifcantly predict mortality [10][11][12][16][17][18][19][20].Trauma victims have better outcomes in developed countries due to well-organized trauma care centers with multidisciplinary teams [21].However, in LMICs including Ethiopia, trauma victims face catastrophic outcomes and complications due to inadequate and underdeveloped rescue systems and the lack of well-established response teams in the health facilities [21][22][23][24].Even though few studies were conducted in Ethiopia among outcomes of abdominal trauma patients, there is variation in the magnitude of outcomes due to diferences in the quality of healthcare and availability of trained trauma management teams.Tis poses difculty for healthcare providers and leaders to make decisions regarding the quality of healthcare provided to abdominal trauma victims.Terefore, detailed evidence on the outcome of abdominal trauma among patients who had undergone laparotomy is needed to improve the quality of care for services provided to trauma patients.Terefore, this study aimed to assess the outcome of abdominal trauma and its predictors in patients who underwent laparotomy at Asella Referral and Teaching Hospital, South Central Ethiopia.

Study Setting and Period.
Te study was conducted at Asella Referral and Teaching Hospital (ARTH) from October 1 to 15, 2020.Te hospital is located in Asella, a zonal town of the Arsi zone.Asella town is located 175 km from Addis Ababa, the capital of Ethiopia.Tere is one public health hospital and 3 health centers in Asella town administration.Te hospital serves as a referral hospital for 9 hospitals in the Arsi zone.Te hospital has a total of approximately 250 beds and more than 500 healthcare providers serving the community.

Study Design and Population.
Tis was an institutionbased cross-sectional study based on a retrospective medical record review over a period of fve years.All patients who had abdominal trauma and underwent exploratory laparotomy for abdominal trauma at ARTH between October 1, 2015, and September 30, 2020, were source population.Te study population included all randomly selected patients who underwent exploratory laparotomy for abdominal trauma at ARTH between October 1, 2015, and September 30, 2020.Abdominal trauma patients who underwent exploratory laparotomy and had incomplete information on medical charts were excluded (Figure 1).

Sample Size and Sampling
Procedure.We estimated the sample size using the single population proportion formula ([n � [(Zα/2)2 * P(1 − P)]/d2]).Te study used the following assumption: 95% confdence level of Zα/2 � 1.96, 5% margin of error, and proportion of mortality after abdominal trauma laparotomy of around 9% from a study done in Addis Ababa [10] and 10% nonresponse rate.Te fnal calculated sample size was 139 records of abdominal trauma patients.Finally, a systematic random sampling method was employed to review the medical records of the study participants.

Study Variables.
Mortality after abdominal trauma laparotomy was the outcome variable, while sociodemographic factors (age, gender, and residence), mechanism of injury (penetrating, blunt, RTA, stab wound, or gunshot wound), Glasgow Coma Scale (GCS) score, associated injuries/extraabdominal injury, splenic injury, splenectomy, liver injury, blood pressure (SBP), blood transfusion, the time interval from incident to admission and from admission to intervention, patient condition during surgery, and length of hospitalization were independent variables.

Operational Defnitions.
Laparotomy: A vertical midline surgical incision through the abdominal wall that allows examination of an abdominal organ.
Death: Te patient was admitted with abdominal trauma, underwent laparotomy, and died in hospital due to a trauma-related illness during treatment before discharge.
Alive: Patients admitted with abdominal trauma requiring laparotomy and started treatment regardless of cause and were discharged alive or cured.
Blood transfusion is a procedure in which whole blood or parts of blood products are transfused to a patient's bloodstream when hemoglobin <7 mg/dl [25,26]. 2 Te Scientifc World Journal Blood products are any therapeutic substances derived from human blood for transfusion including whole blood, packed red blood cells, fresh frozen plasma, platelet concentrates, and cryoprecipitate [25,26].

Data Collection Procedures and Quality Assurance.
Data were collected from the medical records of patients who underwent surgery for abdominal trauma between October 1, 2015, and September 30, 2020, using a data abstraction form designed for this study.We extracted data such as sociodemographic variables, mechanism of injury, Glasgow Coma Scale score, associated injury/extraabdominal injury, splenic injury, splenectomy, liver injury, blood pressure, blood transfusion, the time interval from incident to admission and from admission to intervention, the status of the patient during the operation, the length of hospitalization, and the outcome of the laparotomy.Data were collected by trained medical students from the last years of medicine from the medical records of individual patients.Te principal investigator supervised the overall data collection process and checked the completeness of the data daily.

Data Processing and Analysis.
Te collected data were checked for completeness and consistency.Data were cleaned, entered, processed, and analyzed using the Statistical Package for the Social Sciences (SPSS) version 25.Descriptive statistics such as frequencies and percentages were computed for categorical variables.Continuous variables were summarized using mean and standard deviation.Multivariate logistic regression analysis was performed to determine factors associated with mortality among abdominal trauma patients.All variables with a P value less than or equal to 0.25 in the bivariate logistic regression analysis were considered for the multivariate logistic regression model, and a p value ≤0.05 and an adjusted odds ratio (AOR) with 95% CI were used to declare the factors associated with the outcome variable.We checked multicollinearity using variable infation while Hosmer and Lemeshow goodness-of-ft were computed to determine the ftness of the model.

Ethical Considerations. Te Department of Surgery
Research Ethics Review Board of Arsi University, College of Health Sciences, approved the study (Ref no.: A/CHS/RC// 08/2020), and all methods were performed according to the relevant guidelines and regulations of the university.Te Institutional Review Board of Arsi University waived oral informed consent because the study was conducted through patient chart review.Individual patients were not harmed, and the data were used only in this study.

Sociodemographic Characteristics of the Study
Participants.A total of 139 medical records were included in the study, 110 (79.1% were males, and 88 (63.3%) were aged ≤30 years old.Te mean age of the participants was 29 + 15.73 years.A majority, 110 (79.1%), of the respondents lived in rural areas (Table 1).

Study Participants' Clinical Characteristics at the Time of
Presentation.More than three-ffths (67.6%) of the participants were operated for penetrating mechanisms of injuries.Out of 45 (32.4%) blunt injuries, 25 (55.6%)occurred due to RTA, while 44.4% were related to other types of accidents such as falls, animal kicks, and assault and direct blow injuries.In this study, 93 (66.9%) of patients were presented to the hospital within 6 hours of trauma.Regarding vital signs at presentation, 83 (59.7%) had a systolic blood pressure (SBP) ≥90 mmHg, 83 (59.7%) had a hematocrit greater than 30%, and 74 (53.2%) had a heart rate less than 100 (Table 2).

Discussion
Trauma still accounts for a signifcant number of emergency visits worldwide.Abdominal injuries contribute signifcantly to the morbidity and mortality of trauma patients in most public health facilities [27,28].In this study, the mortality rate for abdominal trauma laparotomy was 15.1% (95% CI: 9.0-21%), which is similar to studies conducted in the Netherlands (16.7%) [29], northern Tanzania (13.2%) [12], and northern Uganda (15.6%) [30].However, these fndings are higher than those of studies conducted in Germany (5.1%) [31], Egypt (7.5%) [13], and Addis Ababa, Ethiopia (8.5%) [10].Te most probable conditions for the discrepancy might be due to variations in the level of setting, accessibility of the healthcare facility, study period, availability of blood/blood products, and trauma management team in the health facilities.In this study, patients who sustained blunt injury mechanisms were nearly eight times more likely to die than those who sustained penetrating injuries.Tis fnding is supported by previous studies conducted by Joseph et al. [18] and Addis Ababa [10].Tis could be the result of associated extraabdominal injuries, which are more common in blunt than in penetrating mechanisms of injury.Patients with blunt abdominal trauma arrived late because there was no outwardly visible trauma, complicating treatment.Another factor found to be signifcantly associated with abdominal trauma laparotomy mortality was SBP <90 mmHg at presentation.Tis fnding is consistent with the fndings of previous studies from Tanzania [12] and Addis Ababa [10].Tis can be caused by bleeding that leads to decomposition before the patient arrives at the hospital.
Te study revealed that patients who were unstable during the intraoperative phase were nearly nine times more likely to die than those who were stable during surgery.Tis is in line with a study conducted in Tanzania [12] and Eastern Ethiopia [32], which found a higher mortality rate in severely injured patients.In addition, the study found higher odds of death in patients who had delayed ≥6 hours to reach the hospital after trauma than in their counterparts.Tis fnding is supported by fndings from a study done in Tanzania [12] and Dilla, South Ethiopia [33].Tis could be because severely injured patients who are delayed in utilizing healthcare services on time might face severe bleeding due to a lack of prehospital care which can lead to death [34].Moreover, this study found a higher probability of death after abdominal trauma among respondents who needed a blood transfusion after an operation than their counterparts.Tis fnding is in line with the study done at Jimma University Specialized Hospital, in southwestern Ethiopia [35].Tis can be explained by the fact that abdominal trauma patients who need blood transfusion might have severe bleeding due to traumatic hemorrhage or a major  Te Scientifc World Journal surgical procedure performed to manage multiple organs damaged that require massive blood transfusion [36][37][38].However, the lack of a well-organized miniblood bank with sufcient blood products to manage severe blood loss that resulted in platelet dysfunction and coagulopathy due to consumption through massive blood transfusion may have contributed to the poor outcomes of these patients.Although our study is the frst to provide insight into the outcome of abdominal trauma laparotomy at the Asella Referral and Teaching Hospital, it has several limitations.First, this study was retrospective, and there was a lack of information on patient characteristics and clinical conditions at presentation and during and after surgery.Second, the study was limited by its single-center nature and small sample size, which afected the analysis of factors associated with the outcome.Tird, the study included patients only up to the day of discharge, undermining the mortality rate.

Conclusion
In this study, penetrating abdominal injury was the most common type of injury.Te proportion of mortality from abdominal trauma among patients who underwent laparotomy was high.Blunt mechanism of injury, SBP <90 mmHg, patient condition during surgery, time ≥6 hours from trauma to admission, and requiring blood transfusion were associated with mortality.Terefore, a health facility should organize a miniblood bank with sufcient blood and blood products in a way that can provide massive blood transfusion at full capacity to reduce mortality due to abdominal trauma.Besides, healthcare providers should provide priority for traumatic patients as the prolonged waiting time to obtain healthcare service results in poor outcomes for patients.

Abbreviations
AOR: Adjusted odds ratio ATLS: Advanced trauma life support BP: Blood pressure CI: Confdence interval COR: Crude odds ratio FAST: Focused assessment with sonography for trauma GCS: Glasgow Coma Scale LOS: Length of stay OR: Odds ratio

Figure 1 :
Figure 1: Flow diagram for study participant recruitment.

Figure 2 :
Figure 2: Procedure performed according to the organ injured.

Table 1 :
Sociodemographic characteristics of abdominal trauma patients at ARTH, South Central Ethiopia, 2020.
with mortality due to abdominal trauma (p ≤ 0.25).However, after adjusting for confounding variables such as time to trauma to admission, blunt mechanism of injury, SBP <90 mmHg at presentation, need for blood transfusion, and intraoperative patient condition showed statistically signifcant association with mortality due to abdominal trauma.Tis study showed that respondents who sustained a blunt patients who had a delay of ≥six hours to reach the hospital after trauma than in their counterparts [AOR � 5.44; 95% CI, 1.78-16.63].Moreover, patients who had unstable intraoperative conditions were almost nine times more likely to die than patients who had stable intraoperative conditions [AOR � 8.82; 95% CI � 3.05-25.52].Te probability of death after abdominal trauma was 6.63 times higher among patients

Table 2 :
Clinical characteristics of abdominal injury patients at the time of presentation at ARTH, South Central Ethiopia, 2020.

Table 3 :
Organ injuries depending on the mechanism of injury of trauma patients treated with laparotomy at ARTH, Asella, 2020.
Note. a Kidney injury, duodenal injury, bladder injury, vascular injury, and retroperitoneal hematoma.

Table 4 :
Postoperative clinical conditions of abdominal trauma patients at ARTH, South Central Ethiopia, 2020.

Table 5 :
Multivariate logistic regression analyses of factors associated with mortality due to abdominal trauma in ARTH patients, South Central Ethiopia, 2020.