Routine Placement of Prophylactic Drain Versus Non-Use of Drain in Patients Undergoing Emergency Open Appendectomy for Complicated Appendicitis at a Tertiary Referral Hospital in Botswana: A Randomized Controlled Trial

Abstract

Objectives  To evaluate the efficacy of the transperitoneal drains in reducing the onset of the postoperative intra-abdominal abscess and surgical-site infection (SSI) following emergency open appendectomy for complicated appendicitis. The study assessed whether utilization of drain was associated with adverse outcomes leading to prolonged hospital stay and increased healthcare expenditure.

Materials and Methods  This was a prospective randomized controlled trial conducted at the Nyangabgwe Referral Hospital, carried out from December 2022 to September 2023. The study included all patients aged 16-years-old and over, with complicated appendicitis, and who underwent emergency open appendectomy. Patients with uncomplicated appendicitis and those scheduled for laparoscopic appendectomy were excluded.

Results  Altogether, 263 participants were consented for the trial, of whom 128 were randomized into the drainage (DG), and 135 into the non-drainage (NDG) groups. A total of 118 patients (44.87%) developed postoperative SSI (DG: 81.35%; NDG: 18.64%; p = 0.001). The length of hospital stay (LOS) was found to be longer in patients with transperitoneal drains than those without (DG: 6 days; NDG: 4 days; p = 0.001). There were three patients (1.14%) who underwent relook laparotomies, two from the DG and one from the NDG (p = 0.304). There was no risk of postoperative intra-abdominal abscess formation between patients belonging to the DG (N = 128) and those in the NDG (N = 135; p < 0.0001). Overall, no mortality was registered in both study groups.

Conclusion  Routine placement of prophylactic transperitoneal drain in patients with complicated appendicitis who undergo emergency open appendectomy shows no statistical improvement over non-usage and, generally, does not avert the onset of postoperative SSI, ileus, or fecal fistula. Moreover, drain usage was linked to prolonged length of hospital stay and increased total healthcare expenditure.

Keywords
complicated acute appendicitis; open appendectomy; abdominal drain; intra-peritoneal abscess; surgical site infection; length of hospital stay

Introduction

Appendicitis refers to inflammation of the vermiform appendix and remains one of the most common indications of emergency surgery worldwide.¹–⁶ It may occur at any age, with the highest incidence in the second and third decades of life.¹–⁴

Its precise etiopathogenesis remains a matter of contention. Nevertheless, the most acceptable theory is attributable to obstruction of the appendiceal lumen from various etiologies leading to increased intraluminal hypertension, vascular congestion, and inflammation of the appendiceal wall. Subsequently leading to localized ischemia, transmural necrosis, and perforation.¹–⁶ This may either be associated with localized abscess formation or generalized peritonitis.³,⁴

Generally, acute appendicitis can be classified in two main categories: uncomplicated and complicated. The latter is characterized by the presence of gangrenous or perforated appendix, with confined or wide-spread peritonitis. This is often attributed to late presentation or misdiagnosis.²,⁴–⁸ Unlike uncomplicated cases, patients with complicated appendicitis have increased risk of developing postoperative sequalae, including surgical-site infection (SSI), intra-abdominal abscess, and ileus.¹,²,⁵,⁶,⁸,⁹

Regardless of its categorization, appendectomy remains the mainstay of treatment for acute appendicitis. Traditionally, surgeons have made use of an intra-abdominal drain as a prophylactic measure to repulse or alleviate the incidence of such adverse outcomes.¹–³,⁵,⁶,⁸,⁹ Nevertheless, this practice has come under great scrutiny in recent decades. The merit of postoperative drainage is anchored upon both therapeutic and prophylactic provisions. Primarily, drains function as conduit appliances through which undesirable intraperitoneal fluids (pus or blood) are removed from the peritoneal cavity.¹⁰,¹¹ Besides, drains may be prophylactically employed to portend early postoperative complications, such as bleeding or anastomotic leakage.¹,²,⁵,¹⁰–¹²

On the other hand, there is an increasing body of evidence from recent published reviews that contradicts this long-standing pedagogical dogma.³,⁹,¹³,¹⁴ The current views suggests that placement of transperitoneal drains after open appendectomy for complicated cases confer no additional therapeutic benefit and may indeed be associated with unfavorable outcomes such as extended duration of hospital stay, prolonged use of antibiotics and overall inflated hospital costs.⁷,⁹,¹²,¹⁴,¹⁵ Additionally, the routine use of trans-peritoneal drain has been restricted by most of the colorectal enhanced recovery after surgery (ERAS) protocols.¹⁶

This ambiguity regarding the pros and cons of routine prophylactic drainage of the abdominal cavity after gastrointestinal surgery has impacted our day-to-day practice, leading to varied viewpoints among surgeons on its use following appendectomy for complicated appendicitis. This stands out as the critical gap, which the present study sought to address in pursuit of evidence-based practice, enhanced patient safety, and provision of high-quality care.

Therefore, the general purpose of this study was to appraise the efficacy of the transperitoneal drains in mitigating the onset of postoperative intra-abdominal abscess and SSI in patients with complicated appendicitis who underwent emergency open appendectomy. Additionally, the study investigated whether drain usage was associated with adverse outcomes leading to lengthened hospital stay and escalating healthcare expenditure.

Materials and Methods

Study Design, Setting, Period, and Registration

The present study was a prospective, randomized, controlled trial. Essentially, a single-center hospital-based study, conducted at the Nyangabgwe Referral Hospital (NRH), Francistown, a government-owned tertiary hospital in Botswana. The study commenced in December 2022 and was concluded in September 2023. The trial was registered with the Health Research and Development Committee (HRDC) from the Ministry of Health, and the NRH's Research and Ethics Committee for research involving human subjects, under registration number HRDC # 00969.

Study Sample and Selection Criteria.

The study sample was defined as patients aged ≥ 16 years, who were admitted to the NRH's Accident and Emergency (A&E) department, with clinical or radiological suspicion of acute appendicitis, and who underwent an emergency open appendectomy. The age cut-off was based on the recommendation by the World Society of Emergency Surgery (WSES) guidelines.¹⁷

Patients were excluded from the study if they had the following: less than 16-years-old, uncomplicated appendicitis; or planned laparoscopic appendectomy. Furthermore, those with malignant conditions, pregnancy, or comorbidities (renal, hepatic, and heart failure) were excluded. Finally, patients who refused to participate in the trial or those with advanced stages of HIV infection did not take part in the study.

Randomization Plan, Allocation, Concealment, and Recruitment

Randomization was attained by a blocked procedure.

Participants were randomized in a 1:1 ratio, being allocated into either arm of the treatment groups: drainage group (DG) and non-drainage group (NDG). In this cohort, randomization process and allocation were performed at the A&E department by an independent research assistant in order to avoid intra- or postoperative allocations, which are beset with potential risk of selection bias. Cards indicating to which group a patient would belong were sealed-off in identical opaque envelopes. Participants who met the eligibility criteria were recruited by the Principal Investigator until the desired sample size was reached. By the nature of the study, blinding surgeons, participants, or assessors was not feasible, as drain placement was unconcealable.

Patients, Initial Evaluation, and Diagnosis

The senior surgeon examined all patients before surgery. The diagnosis of acute appendicitis was determined based on the hospital's treatment guideline, which is centered on good history-taking and physical examination. Laboratory tests such as white blood cell (WBC) count and serum C-reactive protein (CRP), as well as imaging studies, were often employed in the initial evaluation. Ultrasonography was the first-line imaging modality for patients with suspected acute appendicitis; however, where appropriate, adjunct imaging like computed tomography (CT) scan was employed. All the necessary information regarding admission or operation was communicated to the patient, and informed written consent was signed by the patient or a guardian.

Antibiotics, Operative Findings, Postoperative Care, and Data Collection

All patients received preoperative antimicrobial prophylaxis within 60 minutes prior to incision, in the form of intravenous cefotaxime and metronidazole. Antibiotic treatment was continued for a minimum of five days. However, patients with a known allergy to any of the aforementioned antibiotics received an alternative combination. The regimens were similar in type and dosage for both study groups, being revised based on sensitivity results; when indicated, duration of antibiotics was extended. Intraoperative findings were determined and described in detail by an experienced surgeon. In our study, complicated appendicitis was intraoperatively defined as a presence of gangrenous or perforated vermiform appendix, with confined or wide-spread peritonitis. Perforated appendix was confirmed by the presence of discernible puncture in the vermiform appendiceal wall or the existence of a free fecalith within the peritoneal cavity.

Peritoneal lavage was performed after appendectomy until the discharge was sheer clear. For the DG, a Jackson-Pratt drain with a vacuum bulb was used. The insertion was standardized: drains were placed either in the right paracolic gutter or in the pouch of Douglas, and exteriorized through a separate incision away from main surgical incision aiming at circumventing wound contamination. The drain was anchored outside with a nylon stitch; the exit incision was dressed separately from the main surgical incision. Fascial closure was performed in one layer using continuous nonabsorbable suture, and the dermis was either closed or left open for delayed primary closure. The main surgical incision was dressed with a betadine 10% solution. The transperitoneal drain was taken out once it ceased to drain or the amount of effluent decreased to between 20 and 30 mL per day.

It is worth noting that patients with uncomplicated appendicitis would not receive drain and undoubtedly would have been excluded from the study. All resected specimens were subjected to histopathological examination. A homogeneous analgesic regimen was dispensed for pain control during the perioperative period, including injectable morphine and diclofenac. However, when the Visual Analogue Scale (VAS) pain score was lower than 3, patients were transitioned to oral analgesics until pain was fully controlled.

Furthermore, antithrombotic prophylaxis was administered in all high-risk patients during the hospitalization period. Their progress, characteristics, and postoperative parameters were directly recorded by researchers in a validated questionnaire until hospital discharge and follow-up visits. Patients were considered fit for discharge once they met our institution's discharge criteria for complicated appendectomy. Follow-up visits were scheduled at days 14 and 30 following initial discharge.

Outcome Measures

Different types of end-points were recorded and comprehensively compared between the two groups. Primary end-points for this study included: Intraperitoneal abscess, SSI, and length of hospital stay (LOS). Secondary outcomes: Paralytic ileus / bowel obstruction, postoperative abdominal pain, fecal fistula, reintervention procedures, duration of operation, mortality, total hospital costs, and duration of antibiotic/analgesic usage.

• Intra-abdominal abscess was determined by using ultrasound or CT scan in a symptomatic patient (i.e., fever, abdominal pain, or ileus).

• Wound infection and SSI were determined by the researcher, based on clinical signs and symptoms. Signs like erythema, pus discharge, or fever (> 37.5 °C) were monitored. When indicated, pus swab for culture and sensitivity was performed.

• Length of hospital stay was measured in number of days from operation to discharge. A discharge protocol was developed and instituted. In case of readmission, accrued days were added in the duration of hospital-stay calculation.

• Postoperative abdominal pain refers to a persistent abdominal pain following surgery, which warrants further work-up, such as imaging and blood bests. Pain scores were recorded by using a 10 cm VAS score.

• Intestinal obstruction or ileus were determined based on clinical history, investigations (imaging) and physical examination. Abdominal pain, distension, vomiting, and obstipation may all indicate bowel occlusion or ileus.

• Re-intervention: refers to redo / relook procedures such as sonar-guided percutaneous drainage, transrectal drainage, or relaparotomy.

• Fecal fistula was likely when the discharge from the wound or drain had gross consistency of fecal matter.

• The operative time was defined as the total time in minutes from the moment when the skin incision was initiated until the completion of the surgery.

• The total hospital cost was calculated from the overall cost of operations / procedures investigations, medication, consumables and food for the whole period of admission.

• Duration of antibiotic and analgesia usage were extracted from patients' drug sheet and recorded.

• No mortality was registered in both groups. Otherwise, any cases would have been reported, recorded, and investigated, including performing a postmortem, with the report being included in the final analysis.

Data Entry, Analysis, and Presentation

An online Open Data Kit (ODK) form was designed and deployed for data entry after testing. The data from abstraction forms were entered and submitted to the server by use of Android (Open Handset Alliance) phones. Then, all information was downloaded into Excel (Microsoft Corp.) and cleaned for errors and inconsistencies. Cleaned data were then imported into the Stata (StataCorp LLC.) software, version 15, for analysis with the help of a medical statistician.

Meadian and interquartile range (IQR) values were employed to express continuous variables that were abnormally distributed, such as pain scores, LOS, hospital costs, and patients' age. Variables like HIV, sex, and temperature, among others, were managed as categorical data and expressed using proportions. Measures of association, such as the Incidence Risk Ratio (IRR) for different categories, were computed (DG and NDG). The p-values were computed using the Chi-squared test for significance of association. Furthermore, a nonparametric test (Mann-Whitney) was employed to check for significance. The level of statistical significance was measured with p-values of < 0.05. Finally, data were presented by using tables.

Results

From December 2022 to September 2023, a total of 268 eligible patients were admitted to the NRH with clinically or radiologically suspected acute appendicitis, all of whom were approached to participate in this study. There were 5 who did not consent to take part in the trial; therefore, 263 patients were enlisted for this study.

No randomized patient withdrew from the study or got lost to follow-up. There was no crossover instituted throughout the study period. Also, no enlisted patient was excluded from the study. All 263 patients were included in the subsequent analysis, as shown in Fig. 1.

Fig. 1
LOW / Consolidated Standards of Reporting Trials (CONSORT) diagram: overview of original patients.

There were 128 (48.67%) patients randomized into the DG, and 135 (51.33%) in the NDG. Furthermore, 159 patients (60.5%) were male and 104 (39.5%) female, with a slight male predominance. The median age and IQR of the study cohort was 30-years-old (19–42). Overall, the two study groups had similar demographic characteristics, vital signs, white cell count, HIV status, physical signs, presenting symptoms, comparable Alvarado, and initial pain scores. Benchmark data of research entrants are shown in Table 1.

Table 1
Summary of benchmark data for research entrants

Characteristic	Category	Frequency (n)	%
Sex	Female	104	39.5
	Male	159	60.5
Age	Median (IQR)	30 (19–42)
Residence	Rural	139	52.9
	Urban	124	47.1
Employment status	Employed	89	33.8
	Unemployed	173	65.8
	Unknown	1	0.4
Blood pressure	High	5	1.9
	Normal	257	97.7
	Low	1	0.4
Respiratory rate	High	1	0.4
	Normal	261	99.2
	Low	1	0.4
Body temperature (°C)	High (≥ 37.6)	121	46.0
	Normal (36.5–37.5)	142	54.0
HIV status	Negative	210	79.8
	Positive*	53	20.2
Modified Alvarado score	5–6	1	0.4
	7–8	23	8.8
	9–10	239	90.8
WBC count on admission	4–10*10^9	27	10.3
	>10*10^9	236	89.7
VAS scores on admission	Median (IQR)	6 (6–7)

• Abbreviations: IQR, interquartile range; VAS, visual analogue scale; WBC, white blood cell.
• ^*
  Notes: All HIV-positive patients were on antiretroviral therapy with viral load suppression.

Primary and Secondary End-Point Results

There were 118 patients (44.87%) who developed postoperative SSI, with the majority being from the DG (81.35%; NDG: 18.64%; p < 0.001), as shown in Table 2. Also, postoperative paralytic ileus was more frequent in the DG (15.63%; NDG: 4.44%; p < 0.05), as shown in Table 3.

Table 2
Incidence of surgical-site infection

Surgical-site infection	Drain use		Total
	No (n)	Yes (n)
No	113	32	145
Yes	22	96	118
Total	135	128	263

• Notes: Incidence risk ratio = 4.6;p< 0.001.

Table 3
Postoperative incidence of paralytic ileus

Paralytic ileus	Drain use		Total
	No (n)	Yes (n)
No	129	108	237
Yes	6	20	26
Total	135	128	263

• Notes: Incidence risk ratio = 3.5;p< 0.05.

There were three patients (1.14%) who needed re-look laparotomies, of which two originated from the DG and one from the NDG (p = 0.304), as shown in Table 4. It is noteworthy to mention that the trio who underwent second-look laparotomies were the same individuals who developed postoperative fecal fistulas in this cohort (p = 0.304).

Table 4
Postoperative incidence of reintervention procedures

Reoperation	Drain use		Total
	No (n)	Yes (n)
No	134	126	260
Yes	1	2	3
Total	135	128	263

• Notes: IRR = 2.1;p= 0.304.

Strikingly, the study revealed no risk between the two study groups with regard to postoperative intra-abdominal abscess formation (DG: 128; NDG: 135; p< 0.001). Throughout the study there was no postoperative intestinal obstruction recorded in either group. Moreover, there was no loss of life registered. The length of hospital stay was more prolonged in patients with transperitoneal drains than those without (DG: 6 days; NDG: 4 days; p < 0.001). Overall, there was statistical significance found between the DG and NDG regarding the duration of antibiotics usage (p < 0.001), costlier hospital expenditure (p < 0.001), operation time (p < 0.001), postoperative pain (VAS) scores (p < 0.001), and the duration of analgesia usage (p = 0.0288) (Table 5).

Table 5
Data on length of hospital stay, duration of antibiotic/analgesia use, total hospital cost, postoperative VAS scores and operative time

	Non-drainage group: median (IQR)	Drainage group: median (IQR)	p-value
Antibiotic use (days)	5 (5–5)	7 (5–7)	< 0.001
Length of hospital stay (days)	4 (4–5)	6 (6–7)	< 0.001
Total hospital cost (USD)	240 (240–250)	260 (260–270)	< 0.001
Postoperative VAS score	2 (2–3)	3 (2–3)	0.001
Analgesic use (days)	3 (3,3)	3 (3,4)	0.0288
Operative time (minutes)	45 (43–46)	45 (43–47)	< 0.001

• Abbreviations: IQR, interquartile range; USD, United States dollars; VAS, Visual Analogue Scale.

Discussion

This study found the incidence of postoperative SSI to be higher and statistically significant (p < 0.001) in the DG (n = 96, 81.36%) than the NDG (n = 22, 18.64%), which is comparable to previously published series.³,⁹,¹²,¹⁷–¹⁹ These findings indicate that use of trans-peritoneal drain in patients with complicated appendicitis may be associated with increased incidence of SSI.

Critics of routine drain usage in complicated acute appendicitis argues that it may act as a conduit that enhances bacterial relocation, leading to increased risk of wound infection.¹,²,⁷,¹⁹,²⁰ Besides, as a foreign body, the drain has a potential to harbor disease-causing microbes which may consequently heighten risks of SSI.¹,¹⁹ Furthermore, drain insertion may be associated with a number of drawbacks, such as blockage secondary to presence of blood clot, thick-pus, or simply kinking of the tube that may subsequently lead to dysfunction.

Nevertheless, some of the nonrandomized studies in the literature have reported findings contrary to ours and endorsed routine utilization of transperitoneal drains in complicated appendicitis.²¹–²⁴ Their findings suggested that transperitoneal drains reduce postoperative complications and readmission rates. Interestingly, our study revealed no increased risk of postoperative intraperitoneal abscess formation between groups, despite the fact that our cohort had increased rates of perforated appendicitis with confined or diffuse pus formation. The IRR between the study groups was zero, with p < 0.001, which is in stark contrast to the findings of many previous investigators, who have shown that complicated appendicitis is strongly associated with heightened risk of intra-abdominal collection following appendectomy.¹,²,⁹,²⁵,²⁶

Length of hospital stay was one of our primary end-point measures for this cohort, our findings revealed that LOS was prolonged and statistically significant in patients with trans-peritoneal drains than those without. The median and IQR for length of hospital stay in the DG was 6 (IQR: 6–7) days, compared with the NDG's 4 (IQR: 4–5) days, with p < 0.001. Similar observations have been reported in other studies.²,⁷,²⁵ Researchers have highlighted the increased risk of wound infection in the DG as the main cause of extended hospital stay, as most patients with wound infection would be exclusively retained in the hospital for care.⁷,⁹,¹⁹

Additionally, the absence of a drain is likely to reduce postoperative morbidity by relieving patients from the associated pain and the related burden. The lack of drain encourages patients' psychological well-being and, above all, promotes enhanced recovery after surgery (ERAS) pathways. On the other hand, the lengthened hospital-stay had a direct bearing on other outcomes. For instance, patients in the DG utilized more antibiotics and analgesics in comparison with their counterparts in the NDG.

Besides, our study found statistically significant differences between the DG and NDG with regard to the duration of antibiotics usage, total hospital expenditure, operative time, postoperative pain scores and the duration of analgesic usage. The median cost for each patient in the DG was found to be 260 USD, whilst the cost for NDG patients was 240 USD (p < 0.001). The inflated expenditure in the DG group is attributed to accrued cost of acquiring the drainage appliance, and prolonged hospital stay, along with its accompanying cost of consumables including antibiotics and analgesics. These findings are consistent with other series reported in the literature.⁷

The duration of antibiotic usage was longer in the DG (median: 7 days) when compared with the NDG (median: 5 days; p < 0.001). Whereas the IQR for duration of analgesia usage was 3 to 4 days in the DG and 3 days in NDG (p = 0.0288). Presence of transperitoneal drain may have contributed to pain /discomfort, SSI, and lethargy that commensurate to an increased usage of antibiotics and analgesia in patients with drain. These findings are consistent with previous investigators observations.⁷,²⁵

Furthermore, the IQR for operative time was found to be longer in the DG (43–47 min) than in the NDG (43–46 min; p < 0.001). These findings imply that the supplemental process and act of drain insertion in patients assigned to the DG has incrementally lengthened the overall operative time.

With regard to postoperative paralytic ileus, it was found more frequently in patients with transperitoneal drain (n = 20, 7.60%) than in those without (n = 6, 2.28%; p < 0.05). These findings were consistent with results reported in the literature.⁷,¹²,¹⁷,²⁵ Some studies have hypothesized that postoperative ileus may develop as a result of the drain's perpetual irritation to the bowel wall interfering with peristaltic activity.⁹

Moreover, the median for postoperative VAS pain score was found to be 3 for the DG and 2 for the NDG (p < 0.001). As alluded before, physical presence of drain in patients belonging to the DG may have influenced the significant increase of postoperative pain scores in this study group. Similar observations have been reported in the literature.¹²,¹⁵

Out of the 263 patients in our cohort, 3 (1.14%) developed postoperative fecal fistula. Among those, 2 patients (1.56%) came from the DG and 1 (0.74%) belonged to the NDG. Notably, the trio who had undergone reintervention procedures were the same subjects who developed postoperative fecal fistula. However, the aforementioned occurrences were notably scarce and not statistically significant (p = 0.304).

There were two patients who developed postoperative ileal perforation leading to high-output enterocutaneous fistulas, both from the DG, with one 16-year-old female and one 69-year-old male. It was rather difficult to precisely ascertain the cause. Otherwise, initial nonoperative management was not successful in both cases, hence both patients had relook laparotomies performed, whereby wedge-resections were performed followed by end-to-end anastomosis. The third patient was a 29-years-old female from the NDG, who underwent limited right-hemicolectomy due to spontaneous cecal perforation. All three patients did well after reintervention. Nevertheless, the possibility of the drain causing small bowel evisceration, enteric fistula, or bowel obstruction has been highlighted in the literature. Postoperative enteric fistula development following appendicectomy may be caused by an overlooked iatrogenic bowel trauma or leak from the appendiceal radix, secondary to suture slippage.¹²,²⁷,²⁸

Furthermore, this trial found no differences between patients in the DG and those in NDG with regard to mortality and incidence of intestinal obstruction, as there were no recorded cases in the respective study groups. Similar observations have been pointed out in other contemporaries' studies.⁷,¹⁷,¹⁸,²⁵ Nonetheless, a number of investigators have documented a link between drain usage and increased risk of bowel obstruction. In most instances, bowel obstruction was caused either by adhesions or ascribed to prolonged spell of postoperative ileus.⁹,¹²,²⁷,²⁹

Study Strengths, Limitations, and Recommendations

The study has a prospective, randomized, controlled trial design, being deemed appropriate to address our research question. Limitations of this study include it being a single-center study, restricted to open appendectomy, as well as excluding pediatric patients below the age of 16-years, and having a relatively short follow-up period (30 days after hospital admission). All of the aforementioned factors may have prevented some significant findings and, consequently, limit the value of our results as they cannot be easily extrapolated to pediatric or laparoscopically operated patients. We, therefore, recommend a similar comprehensive, sufficiently powered, large-scale, multicenter, prospective, randomized, controlled trial involving both adults and children with long-term follow-up.

Conclusion

Our study found that routine placement of prophylactic transperitoneal drain in patients with complicated appendicitis who undergo urgent emergency open appendectomy has no effectuality edge over non-utilization of drain, and overall does not preclude or substantially lessen susceptibility of these patients from onset of post-surgery sequelae such as SSI, ileus or fecal fistula. Moreover, drain usage was highly linked to lengthy hospital stay which subsequently lead to prolonged spell of antibiotic and analgesia consumption, ultimately hiking the gross healthcare expenditure.

Funding

The authors declare that they did not receive funding from agencies in the public, private or non-profit sectors to conduct the present study.

Ethical Approval

The current study was approved by the Institutional Review Board (IRB), Health Research and Development Committee (HRDC), Ministry of Health of Botswana, and by the Nyangabgwe Referral Hospital (NRH) Research and Ethics Committee for research involving human subjects, under the HRDC number 00969.

Acknowledgements

The author is grateful to patients without whom this study would not have been possible. Furthermore, special appreciation to the research assistants and statistician for their invaluable contribution.

Data Availability

Data will be available upon request to the corresponding author.

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Address for correspondence

Dr. Sefu Juma Uledi, MB. ChB, M. Med (Surgery), Master of Surgery in Principles of Coloproctology, Fellow of the College of Surgeons (FCS) of East, Central and Southern Africa (ECSA), Department of Surgery, Nyangabgwe Referral Hospital, Private Bag 127, Francistown, Botswana (e-mail: [e-mail]).

Conflict of Interests

The author has no conflict of interests to declare.

Editor-in-Chief:

Henrique Fillmann.

Publication Dates

• Publication in this collection
  01 May 2026
• Date of issue
  2026

History

• Received
  19 June 2025
• Accepted
  10 Nov 2025