Global Initiative for Children's Surgery: A Model of Global Collaboration to Advance the Surgical Care of Children

Establishing a Competency Based Medical Education Curriculum for International Medical Graduates Pursuing Pediatric Surgery Training in High-income Countries

PURPOSE

Canada's Royal College of Physicians and Surgeons established a competency-based medical education (CBME) training in pediatric surgery in 2021. Specialty-specific Entrustable Professional Activities (EPAs), foundational to CBME, were created within this framework as tools to assess fellow progression. We aimed to determine which of these EPAs were appropriate for assessment of international medical graduates (IMGs) from Low and Lower-Middle-Income Countries (LMICs) training in pediatric surgery in Canada.

METHODS

Subject matter experts (SMEs) were defined as surgeons with experience in global pediatric surgical education. SMEs were invited to complete a survey tool to assess the relevance of the EPAs for IMG fellows. Each item was rated on a 5-point Likert scale, and narrative comments were collected along with demographic data from respondents. An EPA was determined to be relevant if more than 80 % of SMEs rated it at 4 or higher.

RESULTS

Six SMEs completed the survey. The average duration of experience training pediatric surgery fellows was 13 years, and all SMEs had previously used EPAs for fellow assessment. The average duration of experience supporting LMIC environments was 16 years. Relevance criteria were met for 20 of the 38 EPAs. EPAs not meeting relevance criteria included redundant EPAs, activities not applicable to the LMIC environment, and non-technical skills.

CONCLUSION

EPAs remain a valuable tool for fellow assessment. However, not all the EPAs seem relevant for IMGs training in Canada. Context-relevant education and training programs for LMIC trainees in pediatric surgery are critical to fortifying the global surgical workforce.

Worldwide research tendency and collaborations on models of necrotizing enterocolitis: bibliometric exploration over the past three decades

Background

Necrotizing enterocolitis (NEC) is a devastating disease affecting the gastrointestinal tract in premature infants with high mortality and morbidity. We aimed to analyze the research tendency and collaborations on models of NEC over the past three decades.

Methods

Bibliometric variables of included articles were retrieved from the Web of Science Core Collection from 1994 to 2023. Visualized studies were performed via VOSviewer software. Statistical analysis was applied by using GraphPad Prism and Microsoft Excel.

Result

A total of 255 original articles from 17 countries were included in this study. The number of articles increased significantly from 22 (the year 1994-2003) to 161 (the year 2014-2023) (P < 0.0001). Collaborations in regions and countries have increased significantly over time (P < 0.0001). Developed regions contributed most of the research. While rat (56.08%) held the leading position in all types of models, followed by mouse (30.20%), notably, the proportion of mouse model has increased significantly from 4.55% to 41.36%.

Conclusion

This study might provide valuable insights into the model research of NEC. Research tendency has evolved to be collaborative and inclusive with more collaborations, broad model types, and studies from developing regions. However, the lack of an evident and robust pathophysiology mechanism will continue to make NEC a quite challenging case to decode, and research with strong evidence level and high quality is still required.

Responding to the challenges of Global Children Surgery: a unique program in Burkina Faso

PURPOSE

The challenges are immense when it comes to enhancing the development of pediatric surgery in low- and middle-income countries in line with current recommendations for holistic and sustainable approaches. The Pediatric surgery development plan in Burkina Faso was started in 2020. This paper reports on our unique experience, focusing on the main actions and indicators monitored.

METHODS

The program was developed based on the core principles of the Global Initiative for Children's Surgery, employing a comprehensive health system-strengthening strategy. Our approach aimed to address the pediatric surgical ecosystem through partnerships, research, and interventions at all levels of the healthcare system.

RESULTS

Significant actions were implemented across various domains, including infrastructure, quality of care, workforce, community awareness, research, and advocacy. These efforts have led to a substantial strengthening of the pediatric surgical ecosystem in the country, achieving major milestones and outcomes in each of these areas.

CONCLUSION

This program has not only helped to create a major impulse for the expansion of pediatric surgery in Burkina Faso, but also enriched the community of interest with a robust implementation program to confirm the main challenge to succeed: integrating this most essential discipline into the wider framework of global health.

Burden and mortality of congenital gastrointestinal anomalies: insights from a nationwide cohort study

PURPOSE

Improved perioperative care has enhanced survival in children with congenital gastrointestinal conditions and abdominal wall defects (AWD). However, epidemiological and surgical outcomes in developing nations are still scarce. Our aim was to assess the burden and mortality of common congenital gastrointestinal anomalies and AWD in Malaysia, and their influencing factors.

METHODS

Using the Global PaedSurg study protocol with permission, we performed a prospective cohort study on children presenting for the first time between October 2021 and April 2022 with these conditions: Esophageal atresia (EA), congenital diaphragmatic hernia (CDH), intestinal atresia, gastroschisis, exomphalos, anorectal malformation (ARM) and Hirschsprung's disease. We compared mortality and 30-day outcome data across different geographical regions in Malaysia.

RESULTS

There were 228 patients with 242 study conditions (EA n = 28, CDH n = 36, intestinal atresia n = 49, gastroschisis n = 12, exomphalos n = 8, ARM n = 77, Hirschsprung's disease n = 32). Our mortality rate was 8.8%; 60% of these were CDH patients. Factors significantly associated with mortality were CDH diagnosis, central venous access requirement, higher American Society of Anesthesiologists (ASA) score, blood transfusion and ventilation requirement.

CONCLUSION

Diagnosis of CDH is the most important predictor for sepsis on arrival and mortality, therefore measures should be taken for early recognition and aggressive management.

Fidelity in Academic Global Surgery and Research: Incorporating Trustworthiness in the Development of Research Partnerships, Infrastructure, and Policy

Academic global surgery consists of collaborative partnerships that address surgical inequities through research, training, education, advocacy, and diplomacy. It has been characterized by increased scholastic production through global surgery publications, dedicated global surgery sessions within scientific conferences, global surgery-specific research grants, database development to support global surgery research, global surgery research fellowships, and global surgery-based academic promotion paradigms. The increased emphasis on global surgery research has been accompanied by multiple ethical challenges. This article reviews critical ethical dilemmas presented by global surgery research efforts and proposes interventions on the partnership, infrastructural, and policy levels to enhance fidelity within research partnerships.

Latin American Surgical Outcomes Study in Paediatrics (LASOS-Peds): study protocol and statistical analysis plan for a multicentre international observational cohort study

INTRODUCTION

Surgery is a cost-effective public health intervention. Access to safe surgery is a basic human right. However, there are still significant disparities in the access to and safety of surgical and anaesthesia care between low-income and middle-income countries and high-income countries. The Latin American Surgical Outcomes Study in Paediatrics (LASOS-Peds) is an international, observational, 14-day cohort study to investigate the incidence of 30-day in-hospital complications following elective or emergency paediatric surgery in Latin American countries.

METHODS AND ANALYSIS

LASOS-Peds is a prospective, international, multicentre observational study of paediatric patients undergoing both elective and non-elective surgeries and procedures, inpatient and outpatient, including those performed outside the operating room. The primary outcome is the incidence of in-hospital postoperative complications up to 30 days after surgery. Secondary outcomes include intraoperative complications and the need for intensive care unit admission.

ETHICS AND DISSEMINATION

This study received approval from the Institutional Review Board of the coordinating centre (Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo) as well as from all the participating centres. The study results are expected to be published in peer-reviewed journals and disseminated at international conferences.

TRIAL REGISTRATION NUMBER

NCT05934682.

Pediatric anesthesiology in Brazil, Chile, and Mexico

BACKGROUND

Latin America comprises an extensive and diverse territory composed of 33 countries in the Caribbean, Central, and South America where Romance languages-languages derived from Latin are predominantly spoken. Economic disparities exist, with inequitable access to pediatric surgical care. The Latin American Surgical Outcomes Study in Pediatrics (LASOS-Peds), a multi-national collaboration, will determine safety of pediatric anesthesia and perioperative care.

OBJECTIVE

Below, we provide a descriptive initiative to share how pediatric anesthesia in Brazil, Chile, and Mexico operate. Theses descriptions do not represent all of Latin America.

DESCRIPTIONS AND CONCLUSIONS

Brazil an upper middle-income country, population 203 million, has a public system insufficiently resourced and a private system, resulting in inequitable safety and accessibility. Surgical complications constitute the third leading cause of mortality. Anesthesiology residency is 3 years, with required rotations in pediatric anesthesia; five hospitals offer pediatric anesthesia fellowships. Anesthesiology is a physician-only practice. A Pediatric Anesthesia Committee within the Brazilian Society of Anesthesiology offers education through seasonal courses and workshops including pediatric advanced life support. Chile is a high-income country, population 19.5 million, the majority cared for in the public system, the remainder in university, private, or military systems. Government efforts have gradually corrected the long-standing anesthesiology shortage: twenty 3-year residency programs prepare graduates for routine pediatric cases. The Chilean Society of Anesthesiology runs a 1-month program for general anesthesiologists to enhance pediatric anesthesia skills. Pediatric anesthesia fellowship training occurs in Europe, USA, and Australia, or in two 2-year Chilean university programs. Public health policies have increased the medical and surgical pediatric specialists and general anesthesiologists, but not pediatric anesthesiologists, which creates safety concerns for neonates, infants, and medically complex. Chile needs more pediatric anesthesia fellowship programs. Mexico, an upper middle-income country, with a population of about 126 million, has a five-sector healthcare system: public, social security for union workers, state for public employees, armed forces for the military, and a private "self-pay." There are inequities in safety and accessibility for children. Pediatric Anesthesiology fellowship is 2 years, after 3 years residency. A shortage of pediatric anesthesiologists limits accessibility and safety for surgical care, driven by added training at low salary and hospital under appreciation. The Mexican Society of Pediatric Anesthesiology conducts refresher courses, workshops, and case conferences. Insufficient resources and culture limits research.

Assessment of anesthesia capacity for children in Somaliland

The burden of pediatric surgical conditions in Somaliland is high and the pediatric anesthesia capacity across the country remains poorly understood. The international standards developed by the World Health Organization and World Federation of Societies of Anaesthesiologists (WHO-WFSA) serve as a guideline to assess the provision of anesthetic care. This study aims to describe anesthesia capacity for children in Somaliland and assess progress towards reaching the WHO-WFSA international standards. In this cross-sectional study, anesthesia infrastructure and workforce data, as well as pediatric clinical and demographic data were collected from fifteen private, charity, and government hospitals in the six regions of Somaliland. We described anesthesia capacity in Somaliland and compared baseline data to the WHO-WFSA international standards. Overall, Somaliland did not reach most of the target goals for anesthesia capacity as defined by the WHO-WFSA. Most markers for anesthesia capacity were far behind the established targets, with deficits of 99% for anesthesiologists density, 83% for operating room density, and 83% for ventilator density. Hospitals in urban Maroodi-Jeex, and private hospitals had more supplies, infrastructure, and surgical personnel than hospitals in rural areas. There are large gaps in current anesthetic resources for children according to WHO-WFSA global standards, as well as wide disparities between regions and types of hospitals in Somaliland. Increased investment in anesthesia infrastructure and workforce is required to meet the needs of pediatric surgical patients across the country.

Equitable Partnerships and Programs to Advance Pediatric Global Health

Purpose of the Review

This review underscores the critical need for equitable collaborations to uphold robust and enduring pediatric global health programs to improve child health worldwide. We advocate for the core tenets of reciprocity, longitudinal relationships, and resource redistribution in developing equitable global child health partnerships.

Recent Findings

We reviewed evidence signifying how local and global inequities adversely affect child health. In this review, we provide three examples of successful collaborations between high-income countries and low- and middle-income countries— the Rwandan Human Resources for Health Program, the Global Initiative for Children’s Surgery, and the Baylor College of Medicine International Pediatrics AIDS Initiative— that effectively address these inequities and result in improved child health outcomes. Common themes to equitable partnerships include: (1) prioritizing community voices to inform program development and ensure local needs are met; (2) practicing intentional reciprocity; and (3) challenging outdated and harmful approaches in global health by advocating for a decolonial, socially just, and solidarity-oriented mindset.

Summary

Global pediatric health partnerships must be based on equity to be effective and sustainable. Examples exist whereby programs prioritize community engagement and in-country ownership throughout, ensure reciprocity, and build longitudinal relationships that consider context, historical legacies, systemic inequalities, and promote necessary resource redistribution. These criteria should be used to assess current global child health partnerships and to train the next generation of pediatric global health practitioners, thereby paving the way for a more equitable and sustainable future in pediatric global health.

A review of twenty-first century developments in paediatric surgery in Africa

This review explores the significant advancements in paediatric surgery in Africa during the twenty-first century, with a particular focus on capacity-building, education, infrastructural development, and research. Historically, paediatric surgery has been an overlooked sector, especially in low-and-middle-income countries in Africa. However, recent years have seen considerable progress. Collaborative efforts such as the Global Initiative for Children's Surgery, and the formation of the Pan African Paediatric Surgery Association, the College of Surgeons of East, Central and Southern Africa and the West African College of Surgeons have facilitated knowledge sharing, collaboration, and advocacy for enhancing surgical standards. Local training programmes, including Master of Medicine programmes and fellowships, have been instrumental in building a skilled workforce. These initiatives have been complemented by infrastructural developments through non-governmental organisations like Kids Operating Room, which have expanded access to paediatric surgical care. Technological advancements, particularly in telemedicine, have further enhanced accessibility. Task-sharing strategies, where non-specialist physicians are trained in paediatric surgical skills, have also been utilised to address the shortage of specialised surgeons. Research in paediatric surgery has experienced an upswing, with local health professionals taking the lead. Research has been crucial for understanding the epidemiology of paediatric surgical conditions, and developing prevention strategies, and is increasingly leading to the inclusion of paediatric surgery in national health plans. Despite the progress, challenges remain, including the need for sustainable funding, continued investment in infrastructure, and training and retention of healthcare professionals. The review emphasises the importance of ongoing efforts in community engagement, innovative technologies, and health systems strengthening for the sustainable development of paediatric surgical services in Africa.

Paediatric testicular torsion in low- and middle-income countries: an OxPLORE scoping study

BACKGROUND

Literature on paediatric surgical conditions in low- and middle-income countries (LMICs) remains limited. As a common emergency, timely treatment of testicular torsion acts as a benchmark of adequate emergency service delivery in paediatric surgery. This scoping study aims to synthesise all existing literature on paediatric testicular torsion in LMICs.

METHODS

A database search was conducted by the OxPLORE global paediatric surgery research group to identify studies containing the terms 'testicular torsion' or 'acute scrotum' originating from LMICs. A thematic analysis was applied to the results of the search and the quality of evidence was appraised for all included articles.

RESULTS

This review included 17 studies with 1798 patients. All studies originated from middle-income countries and the majority (76%) had sample sizes smaller than 100 patients. All studies were appraised as providing less than adequate evidence. Included studies identified long delays to treatment and highlighted ongoing debates on the value of scoring systems and Doppler ultrasonography in diagnosing torsion. Major heterogeneity in surgical approaches to treatment of testicular torsion in children was also observed.

CONCLUSIONS

Literature on paediatric testicular torsion in LMICs is scarce and heterogeneous. Prospective, multi-centre research on the management of this common paediatric surgical emergency is urgently required.

Evaluating Global Surgery Partnerships From Low and Middle Income Country Perspectives

INTRODUCTION

Little is known about perceptions of low-income and middle-income country (LMIC) partners regarding global surgery collaborations with high-income countries (HICs).

METHODS

A survey was distributed to surgeons from LMICs to assess the nature and perception of collaborations, funding, benefits, communication, and the effects of COVID-19 on partnerships.

RESULTS

We received 19 responses from LMIC representatives in 12 countries on three continents. The majority (83%) had participated in collaborations within the past 5 y with 39% of collaborations were facilitated virtually. Clinical and educational partnerships (39% each) were ranked most important by respondents. Sustainability of the partnership was most successfully achieved in domains of education/training (78%) and research (61%). The majority (77%) of respondents reported expressing their needs before HIC team arrival. However, 54% of respondents were the ones to initiate the conversation and only 47% said HIC partners understood the overall environment well at arrival to LMIC. Almost all participants (95%) felt a formal process of collaboration and a structured partnership would benefit all parties in assessing needs. During the COVID-19 pandemic, 87% of participants reported continued collaborations; however, 44% of partners felt that relationships were weaker, 31% felt relationships were stronger, and 25% felt they were unchanged.

CONCLUSIONS

Our study provides a snapshot of LMIC surgeons' perspectives on collaboration in global surgery. Independent of location, LMIC partners cite inadequate structure for long-term collaborations. We propose a formal pathway and initiation process to assess resources and needs at the outset of a partnership.

Defining Feasibility as a Criterion for Essential Surgery: A Qualitative Study with Global Children's Surgery Experts

BACKGROUND

The Disease Control Priorities (DCP-3) group defines surgery as essential if it addresses a significant burden, is cost-effective, and is feasible-yet the feasibility component remains largely unexplored. The aim of this study was to develop a precise definition of feasibility for essential surgical procedures for children.

METHODS

Four online focus group discussions (FGDs) were organized among 19 global children's surgery providers with experience of working in low- and lower-middle-income countries (LMICs), representing 10 countries. FGDs were transcribed verbatim, and qualitative data analysis was performed. Codes, categories, themes, and subthemes were identified.

RESULTS

Six determinants of feasibility were identified, including: adequate human resources; adequate material resources; procedure and disease complexity; team commitment and understanding of their setting; timely access to care; and the ability to monitor and achieve good outcomes. Factors unique to feasibility of children's surgery included children's right to health and their reliance on adults for accessing safe and timely care; the need for specialist workforce; and children's unique perioperative care needs. FGD participants reported a greater need for task-sharing and shifting, creativity, and adaptability in resource-limited settings. Resource availability was seen to have a direct impact on decision-making and prioritization, e.g., saving a life versus achieving the best outcome.

CONCLUSIONS

The identification of a precise definition of feasibility serves as a pivotal step in identifying a list of essential surgical procedures for children, which would serve as indicators of institutional surgical capacity for this age group.

A scoping review of the post-discharge care needs of babies requiring surgery in the first year of life

Congenital anomalies are among the leading causes of under-5 mortality, predominantly impacting low- and middle-income countries (LMICs). A particularly vulnerable group are babies with congenital disorders requiring surgery in their first year. Addressing this is crucial to meet SDG-3, necessitating targeted efforts. Post-discharge, these infants have various care needs provided by caregivers, yet literature on these needs is scant. Our scoping review aimed to identify the complex care needs of babies post-surgery for critical congenital cardiac conditions and non-cardiac conditions. Employing the Joanna Briggs Institute's methodological framework for scoping reviews we searched Pubmed, EMBASE, CINAHL, PsychINFO, and Web of Science databases. Search terms included i) specific congenital conditions (informed by the literature and surgeons in the field), ii) post-discharge care, and iii) newborns/infants. English papers published between 2002-2022 were included. Findings were summarised using a narrative synthesis. Searches yielded a total of 10,278 papers, with 40 meeting inclusion criteria. 80% of studies were conducted in High-Income Countries (HICs). Complex care needs were shared between cardiac and non-cardiac congenital conditions. Major themes identified included 1. Monitoring, 2. Feeding, and 3. Specific care needs. Sub-themes included monitoring (oxygen, weight, oral intake), additional supervision, general feeding, assistive feeding, condition-specific practices e.g., stoma care, and general care. The post-discharge period poses a challenge for caregivers of babies requiring surgery within the first year of life. This is particularly the case for caregivers in LMICs where access to surgical care is challenging and imposes a financial burden. Parents need to be prepared to manage feeding, monitoring, and specific care needs for their infants before hospital discharge and require subsequent support in the community. Despite the burden of congenital anomalies occurring in LMICs, most of the literature is HIC-based. More research of this nature is essential to guide families caring for their infants post-surgical care.

Are multidisciplinary consultation meetings for prenatal diagnosis achievable in a low-income country? A descriptive cross-sectional survey in Benin

Objective

The multidisciplinary antenatal diagnosis staff bring together practitioners who are involved in the management of the antenatal period at birth. This project was designed following the French experience to institute multidisciplinary consultation meetings for prenatal diagnosis (MCMPD) in Benin.

Methods

This is a descriptive cross-sectional study examining the knowledge, attitudes, and practices of Beninese practitioners in the field of MCMPD to develop the pilot phase of the project.

Results

We collected 108 participants from different specialties. Pediatricians and pediatric surgeons were in the majority at 23.9% and 16.5%, respectively. Sixty-seven percent of participants were from the public sector (n=75). One practitioner felt that it was not a good idea to implement these meetings. Almost all staff (96.2%) agreed that this meeting would have a positive impact on reducing neonatal mortality. Omphalocele (58.5%), spina bifida aperta (43.6%), and gastroschisis (34%) were the most commonly diagnosed antenatal conditions in Benin. No neonatal pathology required medical termination of the pregnancy according to 35.6% of the participants.

Conclusions

The objective of reducing infant mortality due to medical and surgical pathologies is a noble one and deserves to be supported. This innovative project, developed through this study, the first of its kind in the subregion, will contribute inexorably to the achievement of the third Goal Sustainable Development.

Delivery of essential pediatric congenital surgical care within Brazil's universal health coverage system: a national survey of pediatric surgeons

Objective

In this study, we assess the delivery of congenital pediatric surgical care under Brazil's system of universal health coverage and evaluate differences in delivery between public and private sectors.

Methods

A cross-sectional national survey of pediatric surgeons in Brazil was conducted. Participants were asked which of 23 interventions identified through the Disease Control Priorities 3 (Surgical Interventions for Congenital Anomalies) they perform and to report barriers faced while providing surgical care. Responses were weighted by state and stratified by sector (public vs private).

Results

A sample of 352 responses was obtained and weighted to represent 1378 practicing pediatric surgeons registered in Brazil during the survey time. 73% spend the majority of their time working in the public sector ('Sistema Único de Saúde' and Foundation hospitals), and most of them also work in the private sector. Generally, Brazilian pediatric surgeons have the expertise to provide thoracic, abdominal, and urologic procedures. Surgeons working mostly in the public sector were more likely to report a lack of access to essential medications (25% vs 9%, p<0.01) and a lack of access to hospital beds for surgical patients (52% vs 32%, p<0.01).

Conclusions

Brazilian pediatric surgeons routinely perform thoracic, abdominal, and urologic surgery. Those working in government-financed hospitals face barriers related to infrastructure, which may impact Brazilians who rely on Brazil's universal health coverage system. Policies that support pediatric surgeons working in the public sector may promote the workforce available to provide congenital pediatric surgical care.

Patterns, procedures, and indications for pediatric surgery in a Tanzanian Refugee Camp: a 20-year experience

Background

There are 103 million displaced people worldwide, 41% of whom are children. Data on the provision of surgery in humanitarian settings are limited. Even scarcer is literature on pediatric surgery performed in humanitarian settings, particularly protracted humanitarian settings.

Methods

We reviewed patterns, procedures, and indications for pediatric surgery among children in Nyarugusu Refugee Camp using a 20-year retrospective dataset.

Results

A total of 1221 pediatric surgical procedures were performed over the study period. Teenagers between the ages of 12 and 17 years were the most common age group undergoing surgery (n=991; 81%). A quarter of the procedures were performed on local Tanzanian children seeking care in the camp (n=301; 25%). The most common procedures performed were cesarean sections (n=858; 70%), herniorrhaphies (n=197; 16%), and exploratory laparotomies (n=55; 5%). Refugees were more likely to undergo exploratory laparotomy (n=47; 5%) than Tanzanian children (n=7; 2%; p=0.032). The most common indications for exploratory laparotomy were acute abdomen (n=24; 44%), intestinal obstruction (n=10; 18%), and peritonitis (n=9; 16%).

Conclusions

There is a significant volume of basic pediatric general surgery performed in the Nyarugusu Camp. Services are used by both refugees and local Tanzanians. We hope this research will inspire further advocacy and research on pediatric surgical services in humanitarian settings worldwide and illuminate the need for including pediatric refugee surgery within the growing global surgery movement.

Met and Unmet Need for Pediatric Surgical Access in Uganda: A Country-Wide Prospective Analysis

INTRODUCTION

Children's surgical access in low and low-middle income countries is severely limited. Investigations detailing met and unmet surgical access are necessary to inform appropriate resource allocation.

MATERIALS AND METHODS

Surgical volume, outcomes, and distribution of pediatric general surgical procedures were analyzed using prospective pediatric surgical databases from four separate regional hospitals in Uganda. The current averted burden of surgical disease through pediatric surgical delivery in Uganda and the unmet surgical need based on estimates from high-income country data was calculated.

RESULTS

A total of 8514 patients were treated at the four hospitals over a 6-year period corresponding to 1350 pediatric surgical cases per year in Uganda or six surgical cases per 100,000 children per year. The majority of complex congenital anomalies and surgical oncology cases were performed at Mulago and Mbarara Hospitals, which have dedicated pediatric surgical teams (P < 0.0001). The averted burden of pediatric surgical disease was 27,000 disability adjusted life years per year, which resulted in an economic benefit of approximately 23 million USD per year. However, the average case volume performed at the four regional hospitals currently represents 1% of the total projected pediatric surgical need.

CONCLUSIONS

This investigation is one of the first to demonstrate the distribution of pediatric surgical procedures at a country level through the use of a prospective locally created database. Significant disease burden was averted by local pediatric and adult surgical teams, demonstrating the economic benefit of pediatric surgical care delivery. These findings support several ongoing strategies to increase pediatric surgical access in Uganda.

Assessing the inclusion of children's surgical care in National Surgical, Obstetric and Anaesthesia Plans: a policy content analysis

OBJECTIVE

While National Surgical, Obstetric and Anaesthesia Plans (NSOAPs) have emerged as a strategy to strengthen and scale up surgical healthcare systems in low/middle-income countries (LMICs), the degree to which children's surgery is addressed is not well-known. This study aims to assess the inclusion of children's surgical care among existing NSOAPs, identify practice examples and provide recommendations to guide inclusion of children's surgical care in future policies.

DESIGN

We performed two qualitative content analyses to assess the inclusion of children's surgical care among NSOAPs. We applied a conventional (inductive) content analysis approach to identify themes and patterns, and developed a framework based on the Global Initiative for Children's Surgery's Optimal Resources for Children's Surgery document. We then used this framework to conduct a directed (deductive) content analysis of the NSOAPs of Ethiopia, Nigeria, Rwanda, Senegal, Tanzania and Zambia.

RESULTS

Our framework for the inclusion of children's surgical care in NSOAPs included seven domains. We evaluated six NSOAPs with all addressing at least two of the domains. All six NSOAPs addressed 'human resources and training' and 'infrastructure', four addressed 'service delivery', three addressed 'governance and financing', two included 'research, evaluation and quality improvement', and one NSOAP addressed 'equipment and supplies' and 'advocacy and awareness'.

CONCLUSIONS

Additional focus must be placed on the development of surgical healthcare systems for children in LMICs. This requires a focus on children's surgical care separate from adult surgical care in the scaling up of surgical healthcare systems, including children-focused needs assessments and the inclusion of children's surgery providers in the process. This study proposes a framework for evaluating NSOAPs, highlights practice examples and suggests recommendations for the development of future policies.

Picture Cards Versus Physical Examination: A Proof-of-Concept Study to Improve the SOSAS Survey Tool

INTRODUCTION

The Surgeons OverSeas Assessment of Surgical Needs (SOSAS) survey tool is used to determine the unmet surgical needs in the community and has been validated in several countries. A major weakness is the absence of an objective assessment to verify patient-reported surgically treatable conditions. The goal of this study was to determine whether a picture portfolio, a tool previously shown to improve parental recognition of their child's congenital deformity, could improve the accuracy of the SOSAS tool by how it compares with physical examination. This study focused on children as many surgical conditions in them require prompt treatment but are often not promptly diagnosed.

METHODS

We conducted a descriptive cross-sectional community-based study to determine the prevalence of congenital and acquired surgical conditions among children and adults in a mixed rural-urban area of Lagos, Southwest Nigeria. The picture portfolio was administered only to children and the surgical conditions to be assessed were predetermined using an e-Delphi process among pediatric surgeons. The modified The Surgeons OverSeas Assessment of Surgical Needs-Nigeria Survey Tool (SOSAS-NST) was administered to household members to collect other relevant data. Data were analyzed using the REDCap analytic tool.

RESULTS

Eight hundred and fifty-six households were surveyed. There were 1984 adults (49.5%) and 2027 children (50.5%). Thirty-six children met the predetermined criteria for the picture portfolio-hydrocephalus (n = 1); lymphatic malformation (n = 1); umbilical hernia (n = 14); Hydrocele (n = 5); inguinal hernia (n = 10) and undescended testes (n = 5). The picture portfolio predicted all correctly except a case of undescended testis that was mistaken for a hernia. The sensitivity of the picture portfolio was therefore 35/36 or 97.2%.

CONCLUSIONS

The SOSAS-NST has improved on the original SOSAS tool and within the limits of the small numbers, the picture portfolio has a high accuracy in predicting diagnosis in children in lieu of physical examination.

Key Strategies for Optimizing Pediatric Perioperative Nutrition-Insight from a Multidisciplinary Expert Panel

Adequate nutrition is an essential factor in healing and immune support in pediatric patients undergoing surgery, but its importance in this setting is not consistently recognized. Standardized institutional nutrition protocols are rarely available, and some clinicians may be unaware of the importance of assessing and optimizing nutritional status. Moreover, some clinicians may be unaware of updated recommendations that call for limited perioperative fasting. Enhanced recovery protocols have been used in adult patients undergoing surgery to ensure consistent attention to nutrition and other support strategies in adult patients before and after surgery, and these are now under evaluation for use in pediatric patients as well. To support better adoption of ideal nutrition delivery, a multidisciplinary panel of experts in the fields of pediatric anesthesiology, surgery, gastroenterology, cardiology, nutrition, and research have gathered and reviewed current evidence and best practices to support nutrition goals in this setting.

Impact of new dedicated pediatric operating rooms on surgical volume in Africa: Evidence from Nigeria

BACKGROUND

There is a large unmet children's surgical need in low- and middle-income countries (LMICs). This study examines the impact of installing dedicated pediatric operating rooms (ORs) on surgical volume at National Hospital Abuja, a hospital in Abuja, Nigeria.

METHODS

A Non-Governmental Organization installed two pediatric ORs in August 2019. We assessed changes in volume from July 2018 to September 2021 using interrupted time series analysis.

RESULTS

Total surgical volume increased by 13 cases (p = 0.01) in 1-month post-installation, with elective operations making up 85% (p = 0.02) of cases. There was an increase in elective volume by about 1 case per month (p = 0.01) post-installation and the difference between pre-and post-trends was 1.23 cases per month (p = 0.009). The baseline volume of neonatal surgeries increased by 9 cases per month (p < 0.001) post-installation and this difference between pre- and post-trends was statistically significant (p = 0.001). Similarly, one-month post-installation, the cases classified as ASA class >2 increased by 14 (p < 0.001). There was no significant difference between pre-and post-installation mortality rate at about 2% per month.

CONCLUSIONS

There were significant changes in surgical volume after OR installation, primarily composed of elective operations, reflecting an increased capacity to address surgical backlogs and/or perform more specialized surgeries. Despite a significant increase in volume and higher ASA class, there was no significant difference in mortality. This study supports the installation of surgical infrastructure in LMICs to strengthen capacity without increasing postoperative mortality.

Crucial Business Model Elements for Medical Device Startup Companies in Emerging Markets

OBJECTIVES

Medical devices that suit the needs and challenges of low- and middle-income countries are desperately needed. To provide sustainable access to such devices, business approaches must be developed to meet the demands of individual economic, healthcare, and innovation ecosystems. Currently, there is a gap in the literature regarding business models for medical devices in low- and middle-income countries.

METHODS

A multimodal approach using literature review and key informant interviews was performed to determine critical components of business models for medical device organizations operating in LMICs, specifically focusing on models in emerging markets.

RESULTS

The search resulted in 4,674 articles, of which 31 were determined to be relevant and were reviewed. Additional sources included 1 government website, 5 nongovernmental organization websites, 2 private enterprises, and 6 publicly available, non-peer reviewed websites and 1 video. From these sources, four major criteria were found to be necessary for successful development of medical device business models in emerging markets: value proposition, partnerships, strategic pricing, and funding models.

CONCLUSIONS

Innovators must custom tailor their business model when implementing these elements to the regulatory, cultural, and economic landscapes of each setting. This will improve access to safer, affordable medical care and successfully bring innovative technologies to emerging markets.

The Global Initiative for Children’s Surgery: conception, gestation, and delivery

More than two thirds of the global population lack access to safe, affordable surgical and anesthesia care. This inequity disproportionately affects children in low- and middle-income countries (LMIC). In 2016, a group of pediatric surgical care providers founded the Global Initiative for Children's Surgery (GICS). Their goal was to assemble a multidisciplinary team of specialists and advocates to improve surgical care for children, with a particular emphasis on those in low-resource settings. This review details the history of GICS, the process of its inception, the values guiding its work, its past achievements, and its current initiatives. The experience of GICS may serve as an effective model for global collaboration on other areas of public and global health.

Prevalence of pediatric surgical problems among east African refugees: estimates from a cross-sectional survey using random cluster sampling

IMPORTANCE

Surgery is a foundational aspect to high functioning health care systems. In the wake of the Lancet Commission on Global Surgery, previous research has focused on defining the burden of surgical conditions among a pediatric population, however these studies often fail to include forced migrant or refugees. The goal of this study was to estimate the prevalence of pediatric surgical conditions among refugees in east Africa.

METHODS

We used the previously validated Surgeons OverSeas Assessment of Surgical Need (SOSAS) that utilizes cross-sectional design with random cluster sampling to assess prevalence of surgical disease among participants aged 0 to 18 years in Nyarugusu refugee camp, Tanzania. We used descriptive and multivariable analyses including an average marginal effects model.

RESULTS

A total of 1,658 participants were included in the study. The mean age of our sample was 8.3 ± 5.8 years. A total of 841 participants (50.7%) were male and 817 participants (49.3%) were female. A total of 513 (n = 30.9%) reported a history or presence of a problem that may be surgical in nature, and 280 (54.6%) of them reported the problem was ongoing or untreated. Overall, 16.9% had an ongoing problem that may be amenable to surgery. We found that increasing age and recent illness were associated with having a surgical problem on both our multivariable analyses.

CONCLUSION

To our knowledge, this is the first and largest study of prevalence of surgical conditions among refugee children in sub-Saharan Africa. We found that over 16% (one-in-six) of refugee children have a problem that may be amenable to surgery. Our results provide a benchmark upon which other studies in conflict or post-conflict zones with refugee or forced migrant populations may be compared.

A CT scan-based formula for predicting central venous catheter length in pediatric patients

PURPOSE

Placement of a central venous catheter (CVC) is the most commonly performed pediatric procedure. This study aims to develop simple formulas to calculate intravascular length of CVCs prior to insertion to minimize reliance on fluoroscopic and radiographic imaging, which may not be uniformly available.

METHODS

We performed a single-institution, retrospective review of 115 pediatric patients who received both CVC placement and computed tomography (CT) imaging of the chest within 3 months of the procedure. Using measurements from the CT imaging, formulas calculating the length of the intravascular component of the CVC based on height and insertion laterality were developed and compared to previously published formulas. These formulas were then trialed prospectively to validate reliability and application.

RESULTS

Formulas were developed for right-sided and left subclavian insertion. The right-side formula accurately predicted CVC length in 52.6% of patients, compared to 47.4% by the Andropoulos formula. The left subclavian formula accurately estimated 62.5%, compared to 34.5% by the Stroud formula.

CONCLUSIONS

The optimal intravascular length of central venous catheters may be determined by simple formulas based on patient height and insertion site.

LEVEL OF EVIDENCE

III.

Providing care to children from low and middle-income countries with complex surgical problems: An 18 year review

PURPOSE

The burden of surgical disease in children from low and middle-income countries (LMICs) is becoming more recognized as significant and undertreated.  We recently reviewed our health system's experience with providing quaternary-level surgical care to children from LMICs through a partnership with World Pediatric Project (WPP), a not-for-profit organization.

METHODS

A retrospective review was performed of all WPP-sponsored patients who received surgical care at our children's hospital from LMICs in the Caribbean and Central America from July 2000 to August 2018.

RESULTS

Two hundred and fifty-five patients (average age: 5.9 ± 5.3 years; range: <1-18 years) from 14 countries received a total of 371 moderately to significantly complex operations from 10 pediatric surgical subspecialties, with cardiac, neurosurgery, craniofacial and general/thoracic surgical subspecialties being the most common. The average length of hospital stay was 10.7 ± 18.9 days.  All patients had the opportunity to follow-up with local providers and/or visiting WPP-sponsored surgical teams. 227 patients (93.8%) were seen by WPP providers or released to an in-country physician partnering with WPP. There were 21 (8.2%) total, minor and major, postoperative complications.  Five deaths (2.0%) occurred at our institution and 7 from disease progression, after returning to their home country.

CONCLUSIONS

Providing complex surgical care to LMIC children in the US may help address a significant global burden.  This care can be provided by multiple subspecialists with excellent outcomes, good follow-up, and low complication and mortality rates.  Having a supportive health care system, volunteer surgeons, and an organization that manages logistics and provides financial support is essential.

TYPE OF STUDY

Clinical research, retrospective review LEVEL OF EVIDENCE: Level IV.

Academic Pediatric Surgery Capacity Building in Vietnam Through PASS, a Pediatric Acute Surgical Support Course

Neonatal and pediatric surgical emergencies in Low and Low Middle Income countries remain a significant challenge in combatting the burden and inequities of global health. IPSAC-Vietnam is a small Non-Governmental Organization that has been engaged in a 12-year multi-pronged partnership with several children’s hospitals in Vietnam VN to enhance pediatric surgery capacity. We describe the health care, medical training and emergency system in VN as the background for IPSAC activities and development of Pediatric Acute Surgical Support (PASS) course. The course goal is to prepare health care personnel in the immediate management of neonatal/pediatric life-threatening surgical conditions and road injuries at their first point of entry into Vietnam hospitals. PASS is a horizontal outreach initiative that adopts an interprofessional, multidisciplinary, team-training, train-the-trainers, and outcome-based training approach. PASS can be used as a tool for sustainable horizontal capacity-building by champion leaders at the teaching children’s hospitals and medical universities in developing countries, to strengthen training for pediatric surgical emergencies, to integrate pediatric and pediatric surgical care and to advocate for a comprehensive approach to emergency care of the critically ill child.

An OxPLORE Initiative Evaluating Children's Surgery Resources Worldwide: A Cross-sectional Implementation of the OReCS Document

BACKGROUND

The Global Initiative for Children's Surgery (GICS) group produced the Optimal Resources for Children's Surgery (OReCS) document in 2019, listing standards of children's surgical care by level of healthcare facilities within low resource settings. We have previously created and piloted an audit tool based on the OReCS criteria in a high-income setting. In this study, we aimed to validate its use in identifying gaps in children's surgery provision worldwide.

METHODS

Our OReCS audit tool was implemented in 10 hospitals providing children's surgery across eight countries. Collaborators were recruited via the Oxford Paediatrics Linking Our Research with Electives (OxPLORE) international network of medical students and trainees. The audit tool measured a hospital's current capacity for children's surgery. Data were analysed firstly to express the percentage of 'essential' criteria met for each specialty. Secondly, the 'OxPLORE method' was used to allocate each hospital specialty a level based on procedures performed and resources available. A User Evaluation Tool (UET) was developed to obtain feedback on the ease of use of the tool.

RESULTS

The percentage of essential criteria met within each category varied widely between hospitals. The level given to hospitals for subspecialties based on OReCS criteria often did not reflect their self-defined level. The UET indicated the audit tool was practicable across multiple settings.

CONCLUSIONS

We recommend the use of the OReCS criteria to identify areas for local hospital improvement and inform national children's surgical plans. We have made informed suggestions to increase usability of the OReCS audit tool.

Financing Pediatric Surgery: A Provider's Perspective from the Global Initiative for Children's Surgery

BACKGROUND

Half the world's population is at risk of catastrophic health expenditure (CHE, out-of-pocket spending of more than 10% of annual expenditure) should they require surgery. Protection against CHE is a key indicator of successful health care delivery and has been identified as a priority area by the Global Initiative for Children's Surgery (GICS). Data specific to pediatric surgical patients is limited. This study examines the financial risks for pediatric surgical patients and their families from a provider's perspective.

METHODS

We surveyed GICS members about the existing financial protection mechanisms and estimated expenditures for their patients. Questions were structured based on the National Surgical, Obstetric and Anesthesia Planning Surgical Indicators and finalized based on multi-institutional consensus between high-income country and low-and middle-income country (LMIC) providers. Chi-squared test, Fisher's exact test and student's t-test were used as appropriate.

RESULTS

Among 107 respondents, 72.4% were from low income or lower-middle income (LIC/LMIC) countries, and 55.1% were attending or consultant physicians. Families were most likely to decline surgery in LIC/LMIC due to inability to afford treatment (mean Likert = 3.77 ± 1.06). The odds of incurring CHE after children's surgery are up to 17 times greater in LIC/LMIC (P = 0.001, unadjusted OR 17.28, 95%CI 2.13-140.02). Over 50% of families of children undergoing major surgery in these settings face CHE. An estimated 5.1% of providers in LIC/LMIC and 56.2% (P < 0.001) of providers in UMIC/HIC reported that families are able to pay for their direct medical costs with the assistance available to them and were more likely to sell assets (74.4% vs. 33.3%, P = 0.005).

CONCLUSION

Patients in LMICs are at greater risk for CHE and have less financial risk protection than their HIC counterparts. Given this disparity, intervention is needed to make safe surgery affordable for children worldwide.

Pediatric Surgery and Anesthesia in Low-Middle Income Countries: Current Situation and Ethical Challenges

Low-middle income countries (LMICs) are currently experiencing an important population growth, leading to a substantial raise in the number of children living in those areas. As a consequence, the existing gap between the need for surgical and anesthetic care and the available therapeutic options will increase. To overcome this, an improvement in the available expertise, infrastructures, and supplies will be mandatory. The implementation of educational and training programs for local healthcare providers should be a top priority. Alongside, the population's awareness on the necessity to seek for medical care should be deployed, together with an eased access to health facilities. Based on the existing literature and our 20-years' experience in humanitarian missions, our article aims to investigate the status of pediatric surgery in LMICs, and the role of western aids in the implementation of this ever-increasing field of expertise.

Analysis of challenges faced and the scientific content of a hybrid pediatric surgical conference arranged during the COVID-19 pandemic

Background

Scientific conferences which are considered as an important event for dissemination of research and related academic activities were badly affected during the COVID-19 pandemic. Virtual format for interaction was used as an alternative method to continue such academic discourse. However, this did not provide the same level of communication and interest as that of in-person meetings. With evolving knowledge about the COVID-19 pandemic especially its transmission, role of vaccine, and observing standard operating procedures (SOPs), fear among healthcare providers is mitigated to some extent. Keeping in mind the importance of scientific conferences in the context of sharing knowledge and its impact on the training of faculty members and postgraduate residents, a hybrid conference was planned by the national association of pediatric surgeons.The purpose of this study was to retrospectively review the challenges faced during the organization of this conference as well as to analyze the pattern of registration, number of abstracts received, the gender of the participants and their status, region of the country they represented, type of presentation made, and scientific subject covered. SPSS version 22 was used for data entry. Descriptive and inferential statistics were used to present data. Chi square test was applied to find out the association between categorical variables and a p value < 0.05 was considered as significant.

Results

A total of 170 pediatric surgeons and postgraduate residents participated from all over the country and abroad. Nearly half (47.1%) of the registrants were postgraduate residents. Most of the participants (90%) opted for in-person attendance. The venue was selected with a capacity to house more than double the number of registrants with provision of safe distance. Availability of face masks, gloves, and sanitizers was ensured by the organizers. Packed meal boxes were arranged and served at the venue site in an open place on the terrace. A total of 97 abstracts were accepted for presentation that included 57 (58.8%) long oral podium and 40 (41.2%) poster presentations. Most of the studies (n=48-49.4%) were related to the subject of gastroenterology including pancreatico-hepatobiliary system and spleen. Majority of the presenters were male (p = 0.046) and postgraduate residents (p = 0.001).

Conclusion

It was possible to organize a hybrid annual medical conference where most of the participants preferred physical presence. A rich scientific program was made to cater the needs for pediatric surgical fraternity. Residents made attractive presentations. It was noted that physical presence during clinical conference produced effective communication and learning.

Paediatric surgical outcomes in sub-Saharan Africa: a multicentre, international, prospective cohort study

INTRODUCTION

As childhood mortality from infectious diseases falls across sub-Saharan Africa (SSA), the burden of disease attributed to surgical conditions is increasing. However, limited data exist on paediatric surgical outcomes in SSA. We compared the outcomes of five common paediatric surgical conditions in SSA with published benchmark data from high-income countries (HICs).

METHODS

A multicentre, international, prospective cohort study was undertaken in hospitals providing paediatric surgical care across SSA. Data were collected on consecutive children (birth to 16 years), presenting with gastroschisis, anorectal malformation, intussusception, appendicitis or inguinal hernia, over a minimum of 1 month, between October 2016 and April 2017. Participating hospitals completed a survey on their resources available for paediatric surgery.The primary outcome was all-cause in-hospital mortality. Mortality in SSA was compared with published benchmark mortality in HICs using χ² analysis. Generalised linear mixed models were used to identify patient-level and hospital-level factors affecting mortality. A p<0.05 was deemed significant.

RESULTS

1407 children from 51 hospitals in 19 countries across SSA were studied: 111 with gastroschisis, 188 anorectal malformation, 225 intussusception, 250 appendicitis and 633 inguinal hernia. Mortality was significantly higher in SSA compared with HICs for all conditions: gastroschisis (75.5% vs 2.0%), anorectal malformation (11.2% vs 2.9%), intussusception (9.4% vs 0.2%), appendicitis (0.4% vs 0.0%) and inguinal hernia (0.2% vs 0.0%), respectively. Mortality was 41.9% (112/267) among neonates, 5.0% (20/403) in infants and 1.0% (7/720) in children. Paediatric surgical condition, higher American Society of Anesthesiologists score at primary intervention, and needing/receiving a blood transfusion were significantly associated with mortality on multivariable analysis.

CONCLUSION

Mortality from common paediatric surgical conditions is unacceptably high in SSA compared with HICs, particularly for neonates. Interventions to reduce mortality should focus on improving resuscitation and timely transfer at the district level, and preoperative resuscitation and perioperative care at paediatric surgical centres.

Commentary on bilateral Wilms' tumour: An international comparison of treatments and outcomes

This is a commentary on the manuscript titled "Bilateral wilms' tumour: An international comparison of treatments and outcomes" by Drysdale H, Fawkner-Corbett D, Solomon Z, et al.

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

BACKGROUND

Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality.

METHODS

We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung's disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis.

FINDINGS

We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung's disease) from 264 hospitals (89 in high-income countries, 166 in middle-income countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36-39) and median bodyweight at presentation was 2·8 kg (2·3-3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in low-income countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88-4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59-2·79], p<0·0001), sepsis at presentation (1·20 [1·04-1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4-5 vs ASA 1-2, 1·82 [1·40-2·35], p<0·0001; ASA 3 vs ASA 1-2, 1·58, [1·30-1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02-1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41-2·71], p=0·0001; parenteral nutrition 1·35, [1·05-1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47-0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50-0·86], p=0·0024) or percutaneous central line (0·69 [0·48-1·00], p=0·049) were associated with lower mortality.

INTERPRETATION

Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between low-income, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030.

FUNDING

Wellcome Trust.

Ten Global Surgical Care Statements for Children: examining our commitment to the future

BACKGROUND

The lack of access to essential surgery for many of our world's children is a global health crisis. A third of all deaths in the pediatric population are due to surgical conditions. In low- and middle-income countries, an average of nine in ten children lack access to basic surgical care.

METHODS

This review examines ten commitment statements ratified by numerous global pediatric surgical organizations aimed at addressing existing gaps in global surgical care for children. They are substantiated by a review of literature and represent over-arching principles.

RESULTS

They prompt the recognition of childhood surgical disease as a global health priority and advocate for availability to safe surgical and anesthetic care. Calls to action highlight the importance of capacity building in the areas of education, data gathering, workforce, research, and international collaborations.

DISCUSSION

Eventually, there is the hope for widespread approval of the guiding principles they represent and that the statements themselves, as encapsulations of these beliefs, may act as a continued call for advocacy and action for the necessary work, resources, and funding to mitigate global pediatric surgical disparities.

Global and regional overview of the inclusion of paediatric surgery in the national health plans of 124 countries: an ecological study

OBJECTIVE

This study evaluates the priority given to surgical care for children within national health policies, strategies and plans (NHPSPs).

PARTICIPANTS AND SETTING

We reviewed the NHPSPs available in the WHO's Country Planning Cycle Database. Countries with NHPSPs in languages different from English, Spanish, French or Chinese were excluded. A total of 124 countries met the inclusion criteria.

PRIMARY AND SECONDARY OUTCOME MEASURES

We searched for child-specific and surgery-specific terms in the NHPSPs' missions, goals and strategies using three analytic approaches: (1) count of the total number of mentions, (2) count of the number of policies with no mentions and (3) count of the number of policies with five or more mentions. Outcomes were compared across WHO regional and World Bank income-level classifications.

RESULTS

We found that the most frequently mentioned terms were 'child*', 'infant*' and 'immuniz*'. The most frequently mentioned surgery term was 'surg*'. Overall, 45% of NHPSPs discussed surgery and 7% discussed children's surgery. The majority (93%) of countries did not mention selected essential and cost-effective children's procedures. When stratified by WHO region and World Bank income level, the West Pacific region led the inclusion of 'pediatric surgery' in national health plans, with 17% of its countries mentioning this term. Likewise, low-income countries led the inclusion of surg* and 'pediatric surgery', with 63% and 11% of countries mentioning these terms, respectively. In both stratifications, paediatric surgery only equated to less than 1% of the total terms.

CONCLUSION

The low prevalence of children's surgical search terms in NHPSPs indicates that the influence of surgical care for this population remains low in the majority of countries. Increased awareness of children's surgical needs in national health plans might constitute a critical step to scale up surgical system in these countries.

Access to pediatric surgery delivered by general surgeons and anesthesia providers in Uganda: Results from 2 rural regional hospitals

BACKGROUND

Significant limitations in pediatric surgical capacity exist in low- and middle-income countries, especially in rural regions. Recent global children's surgical guidelines suggest training and support of general surgeons in rural regional hospitals as an effective approach to increasing pediatric surgical capacity.

METHODS

Two years of a prospective clinical database of children's surgery admissions at 2 regional referral hospitals in Uganda were reviewed. Primary outcomes included case volume and clinical outcomes of children at each hospital. Additionally, the disability-adjusted life-years averted by delivery of pediatric surgical services at these hospitals were calculated. Using a value of statistical life calculation, we also estimated the economic benefit of the pediatric surgical care currently being delivered.

RESULTS

From 2016 to 2019, more than 300 surgical procedures were performed at each hospital per year. The majority of cases were standard general surgery cases including hernia repairs and intussusception as well as procedures for surgical infections and trauma. In-hospital mortality was 2.4% in Soroti and 1% in Lacor. Pediatric surgical capacity at these hospitals resulted in over 12,400 disability-adjusted life-years averted/year. This represents an estimated economic benefit of 10.2 million US dollars/year to the Ugandan society.

CONCLUSION

This investigation demonstrates that lifesaving pediatric procedures are safely performed by general surgeons in Uganda. General surgeons who perform pediatric surgery significantly increase surgical access to rural regions of the country and add a large economic benefit to Ugandan society. Overall, the results of the study support increasing pediatric surgical capacity in rural areas of low- and middle-income countries through support and training of general surgeons and anesthesia providers.

Potentially Avertable Child Mortality Associated with Surgical Workforce Scale-up in Low- and Middle-Income Countries: A Global Study

BACKGROUND

Expansion of access to surgical care can improve health outcomes, although the impact that scale-up of the surgical workforce will have on child mortality is poorly defined. In this study, we estimate the number of child deaths potentially avertable by increasing the surgical workforce globally to meet targets proposed by the Lancet Commission on Global Surgery.

METHODS

To estimate the number of deaths potentially avertable through increases in the surgical workforce, we used log-linear regression to model the association between surgeon, anesthetist and obstetrician workforce (SAO) density and surgically amenable under-5 mortality rate (U5MR), infant mortality rate (IMR), and neonatal mortality rate (NMR) for 192 countries adjusting for potential confounders of childhood mortality, including the non-surgical workforce (physicians, nurses/midwives, community health workers), gross national income per capita, poverty rate, female literacy rate, health expenditure per capita, percentage of urban population, number of surgical operations, and hospital bed density. Surgically amenable mortality was determined using mortality estimates from the UN Inter-agency Group for Child Mortality Estimation adjusted by the proportion of deaths in each country due to communicable causes unlikely to be amenable to surgical care. Estimates of mortality reduction due to upscaling surgical care to support the Lancet Commission on Global Surgery (LCoGS) minimum target of 20-40 SAO/100,000 were calculated accounting for potential increases in surgical volume associated with surgical workforce expansion.

RESULTS

Increasing SAO workforce density was independently associated with lower surgically amenable U5MR as well as NMR (p < 0.01 for each model). When accounting for concomitant increases in surgical volume, scale-up of the surgical workforce to 20-40 SAO/100,000 could potentially prevent between 262,709 (95% CI 229,643-295,434) and 519,629 (465,046-573,919) under 5 deaths annually. The majority (61%) of deaths averted would be neonatal deaths.

CONCLUSION

Scale up of surgical workforce may substantially decrease childhood mortality rates around the world. Our analysis suggests that scale-up of surgical delivery through increase in the SAO workforce could prevent over 500,000 children from dying before the age of 5 annually. This would represent significant progress toward meeting global child mortality reduction targets.

Current Status of Training and Certification for Congenital Heart Surgery Around the World: Proceedings of the Meetings of the Global Council on Education for Congenital Heart Surgery of the World Society for Pediatric and Congenital Heart Surgery

The optimal training of the highly specialized congenital heart surgeon is a long and complex process, which is a significant challenge in most parts of the world. The World Society for Pediatric and Congenital Heart Surgery (WSPCHS) has established the Global Council on Education for Congenital Heart Surgery as a nonprofit organization with the goal of assessing current training and certification and ultimately establishing standardized criteria for the training, evaluation, and certification of congenital heart surgeons around the world. The Global Council and the WSPCHS have reviewed the present status of training and certification for congenital cardiac surgery around the world. There is currently lack of consensus and standardized criteria for training in congenital heart surgery, with significant disparity between continents and countries. This represents significant obstacles to international job mobility of competent congenital heart surgeons and to the efforts to improve the quality of care for patients with Congenital Heart Disease worldwide. The purpose of this article is to summarize and document the present state of training and certification in congenital heart surgery around the world.

Capacity for paediatric radiology in Nigeria: a survey of radiologists

Children account for nearly half the population of Nigeria yet the capacity for effective imaging of children is unknown. In order to determine clinical resources for and challenges of paediatric radiology in Nigeria, certified radiologists at an exit examination in radiology for resident doctors, and resident doctors in radiology attending an update course, completed a semi-structured questionnaire detailing personal information, radiology training, practice and perceived priorities of paediatric radiology in Nigeria. Of 100 questionnaires, 80 were returned, completed (80%) by 46 (58%) certified radiologists, 14 (18%) senior and 20 (25%) junior radiology residents. Only 1 (2.2%) certified radiologist received dedicated albeit short training in paediatric radiology. Nine (20.0%) certified radiologists and 1 (2.9%) resident doctor target their practice to paediatric imaging. Only 2 (4.4%) certified radiologists devote at least half of their time to paediatric radiology. Forty-two (91%) of the certified radiologists are not aware of any radiologist primarily affiliated with a dedicated children's hospital or who practices in a dedicated paediatric unit of a mixed hospital. Eight (19%) radiologists work in a facility with a consultant who has some training in paediatric radiology. Surgeons (64%), neonatologists (53%) and neurologists (45%) were the other paediatric specialties usually available where the respondent works. Fourteen (4.9%), 4 (2.1%), and 1 (1.3%) ultrasound, X-ray and magnetic resonance imaging (MRI) units, respectively, were reserved for paediatric imaging while no fluoroscopy or computed tomography (CT) unit was dedicated to children. Lack of dedicated equipment (44%) and trained paediatric radiologists (24%) were the main challenges to paediatric imaging as perceived by the respondents. Substantial deficits in human and material resources require informed investment in dedicated equipment and training to boost capacity for paediatric radiology in Nigeria.

Development of an Interactive Global Surgery Course for Interdisciplinary Learners

Introduction:

Global surgical care is increasingly recognized in the global health agenda and requires multidisciplinary engagement. Despite high interest among medical students, residents and other learners, many surgical faculty and health experts remain uniformed about global surgical care.

Methods:

We have operated an interdisciplinary graduate-level course in Global Surgical Care based on didactics and interactive group learning. Students completed a pre- and post-course survey regarding their learning experiences and results were analyzed using the Wilcoxon signed-rank test.

Results:

Fourteen students completed the pre-course survey, and 11 completed the post-course survey. Eleven students (79%) were enrolled in a Master’s degree program in global health, with eight students (57%) planning to attend medical school. The median ranking of surgery on the global health agenda was fifth at the beginning of the course and third at the conclusion (p = 0.11). Non-infectious disease priorities tended to stay the same or increase in rank from pre- to post-course. Infectious disease priorities tended to decrease in rank (HIV/AIDS, p = 0.07; malaria, p = 0.02; neglected infectious disease, p = 0.3). Students reported that their understanding of global health (p = 0.03), global surgery (p = 0.001) and challenges faced by the underserved (p = 0.03) improved during the course. When asked if surgery was an indispensable part of healthcare, before the course 64% of students strongly agreed, while after the course 91% of students strongly agreed (p = 0.3). Students reported that the interactive nature of the course strengthened their skills in collaborative problem-solving.

Conclusions:

We describe an interdisciplinary global surgery course that integrates didactics with team-based projects. Students appeared to learn core topics and held a different view of global surgery after the course. Similar courses in global surgery can educate clinicians and other stakeholders about strategies for building healthy surgical systems worldwide.

Nutritional status and outcome of surgery: A prospective observational cohort study of children at a tertiary surgical hospital in Harare, Zimbabwe

BACKGROUND

Undernutrition contributes to nearly 50% of all child deaths in the world, yet there is conflicting evidence regarding the association between nutritional status and postoperative complications. The aim was to describe the preoperative nutritional status among pediatric surgery patients in Zimbabwe, and to assess if nutritional status was a risk factor for adverse postoperative outcome of mortality, surgical site infection, reoperation, readmission, and longer length of stay.

METHODS

This prospective observational cohort study included 136 children undergoing surgery at a tertiary pediatric hospital in Zimbabwe. Nutritional status was standardized using Z-scores for BMI, length, weight, and middle upper arm circumference. Primary outcomes after 30 days included mortality, surgical site infection, reoperation, and readmission. Secondary outcome was length of stay. Univariate and multivariable analyses with logistic regression were performed.

RESULTS

Of the 136 patients, 31% were undernourished. Postoperative adverse outcome occurred in 20%; the mortality rate was 6%, the surgical site infection rate was 17%, the reoperation rate was 3.5%, and readmission rate was 2.5%. Nutritional status, higher ASA classification, major surgical procedures, and lower preoperative hemoglobin levels were associated with adverse outcome. Univariate logistic regression identified a seven-fold increased risk of postoperative complications among undernourished children (OR 7.3 [2.3-22.8], p = 0.001), and there was a four- to six-fold increased adjusted risk after adjustment for ASA, major surgery, and preoperative hemoglobin.

CONCLUSION

A third of all pediatric surgery patients were undernourished, and undernourished children had a considerably higher risk of adverse outcome. With a positive correlation identified between undernourishment and increased postoperative complications, future aims would include assessing if preoperative nutritional treatment could be especially beneficial for undernourished children.

LEVELS OF EVIDENCE

Level II treatment study.

Barriers to Surgical Care Among Children in Somaliland: An Application of the Three Delays Framework

BACKGROUND

There are complex barriers that increase delays to surgical care in low- and middle-income countries, particularly among the vulnerable population of children. Understanding these barriers to surgical care can result in targeted and strategic intervention efforts to improve care for children. The three-delay model is a widely used framework in global health for evaluating barriers associated with seeking (D1), reaching (D2), and receiving health care (D3). The goal of our study is to evaluate reasons for delays in the surgical care for children in Somaliland using the three-delay framework.

METHODS

Data were collected in a cross-sectional study in Somaliland from 1503 children through a household survey. Among children with a surgical need, we quantified the number of children seeking, reaching, and receiving care along the surgical care continuum, according to the three-delay framework. We evaluated predictors of the three delays through a multivariate logistic regression model, including the child's age, gender, village type, household income level, region, and household size.

RESULTS

Of the 196 children identified with a surgical condition, 50 (27.3%) children had a delay in seeking care (D1), 28 (20.6%) children had a delay in reaching care (D2), and 84 (71.2%) children had a delay in receiving care (D3), including 10 children who also experienced D1 and D2. The main reasons cited for D1 included seeking a traditional healthcare provider, while lack of money and availability of care were main reasons cited for D2. Significant predictors for delays included household size for D1 and D3 and condition type and region for D2.

CONCLUSION

Children in Somaliland experience several barriers to surgical care along the entire continuum of care, allowing for policy guidance tailored to specific local challenges and resources. Since delays in surgical care for children can substantially impact the effectiveness of surgical interventions, viewing delays in surgical care under the lens of the three-delay framework can inform strategic interventions along the pediatric surgical care continuum, thereby reducing delays and improving the quality of surgical care for children.

Interpreting the Lancet surgical indicators in Somaliland: a cross-sectional study

BACKGROUND

The unmet burden of surgical care is high in low-income and middle-income countries. The Lancet Commission on Global Surgery (LCoGS) proposed six indicators to guide the development of national plans for improving and monitoring access to essential surgical care. This study aimed to characterise the Somaliland surgical health system according to the LCoGS indicators and provide recommendations for next-step interventions.

METHODS

In this cross-sectional nationwide study, the WHO's Surgical Assessment Tool-Hospital Walkthrough and geographical mapping were used for data collection at 15 surgically capable hospitals. LCoGS indicators for preparedness was defined as access to timely surgery and specialist surgical workforce density (surgeons, anaesthesiologists and obstetricians/SAO), delivery was defined as surgical volume, and impact was defined as protection against impoverishment and catastrophic expenditure. Indicators were compared with the LCoGS goals and were stratified by region.

RESULTS

The healthcare system in Somaliland does not meet any of the six LCoGS targets for preparedness, delivery or impact. We estimate that only 19% of the population has timely access to essential surgery, less than the LCoGS goal of 80% coverage. The number of specialist SAO providers is 0.8 per 100 000, compared with an LCoGS goal of 20 SAO per 100 000. Surgical volume is 368 procedures per 100 000 people, while the LCoGS goal is 5000 procedures per 100 000. Protection against impoverishing expenditures was only 18% and against catastrophic expenditures 1%, both far below the LCoGS goal of 100% protection.

CONCLUSION

We found several gaps in the surgical system in Somaliland using the LCoGS indicators and target goals. These metrics provide a broad view of current status and gaps in surgical care, and can be used as benchmarks of progress towards universal health coverage for the provision of safe, affordable, and timely surgical, obstetric and anaesthesia care in Somaliland.