Clinical Profile, Risk Factors and Surgical Outcomes of Neonatal Emergencies: A Retrospective Observational Cohort Study from a Tertiary Care Hospital

Abstract

Background:Neonatal surgical emergencies remain among the most demanding problems in paediatric surgical practice. Survival in high-income settings now routinely exceeds ninety per cent for most index conditions, yet reported mortality from tertiary centres in South Asia continues to sit between fifteen and forty per cent. Observational data from such centres suggest that this gap is driven less by the operation itself than by everything that surrounds it: late recognition, unstabilised transport, sepsis acquired before the neonate ever reaches a surgeon, and constrained neonatal intensive care capacity.

Objectives

To describe, through observation of a consecutive clinical cohort, the demographic and clinical profile of neonates undergoing emergency surgery at a tertiary referral hospital; to quantify the spectrum of diagnoses and their case fatality; and to identify, by statistical association rather than experimental manipulation, independent perinatal, referral-related and intraoperative correlates of in-hospital mortality.

Methods:This was a retrospective, single-centre, purely observational cohort study. No intervention of any kind was introduced, withheld, or altered by the investigators; every neonate received whatever care was clinically indicated by the treating team, entirely independent of, and prior to, this research. We reviewed case records, operation notes, anaesthetic charts and neonatal intensive care unit flow sheets for all neonates aged twenty-eight days or less who underwent emergency surgical treatment between January 2021 and December 2023, against a pre-piloted proforma. The primary outcome was in-hospital mortality; secondary outcomes were major postoperative morbidity graded by the Clavien–Dindo classification, duration of mechanical ventilation and length of stay. Variables associated with mortality at a significance threshold of p < 0.10 on univariate testing were entered into a multivariable logistic regression model to identify independent statistical correlates; model discrimination was assessed by the area under the receiver operating characteristic curve. As an observational design, this study can identify association, not causation.

Results: Of 412 neonatal admissions screened, 174 operated neonates formed the analytic cohort. The male-to-female ratio was 1.9:1, median gestational age was 37 weeks (interquartile range 34–38) and median birth weight was 2,480 g (interquartile range 2,050–2,840). Anorectal malformation (23.6%), congenital intestinal obstruction (18.4%) and oesophageal atresia with tracheo-oesophageal fistula (14.4%) accounted for more than half of all admissions. Overall in-hospital mortality was 25.3% (44 of 174). Case fatality was highest for congenital diaphragmatic hernia (47.1%), necrotising enterocolitis (42.9%) and oesophageal atresia (36.0%). On multivariable analysis, inotrope requirement (adjusted odds ratio 5.02, 95% CI 1.97–12.79), pre-operative sepsis (aOR 4.56, 95% CI 1.93–10.78), birth weight below 1,500 g (aOR 3.82, 95% CI 1.42–10.27), intraoperative bowel perforation (aOR 3.14, 95% CI 1.28–7.71) and referral delay exceeding forty-eight hours (aOR 2.87, 95% CI 1.21–6.81) were independently associated with death after adjustment for one another. The model achieved an area under the curve of 0.86.

Conclusions:In this observational cohort, mortality after neonatal emergency surgery was more strongly associated with pre-operative physiological state than with the anatomical diagnosis alone. Four of the five independent correlates identified describe features that are, in principle, modifiable earlier antenatal detection, structured referral pathways, protocol-driven transport and pre-operative stabilisation but because this was a non-interventional study, it cannot demonstrate that modifying them would causally reduce mortality; it can only identify them as priority targets for future prospective or interventional evaluation. The strength and consistency of the association between the pre-operative interval and mortality suggest that this interval, rather than further refinement of operative technique, is where such future interventional research would be best directed.

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