From the editors: The COVID-19 crisis and its implications for pediatric surgeons

COVID-19 positive cases in a pediatric surgery department from Romania: Case series from 2 years of pandemics

RATIONALE

The COVID-19 pandemic had a dramatic effect on various health systems in terms of admissions and outcomes, including pediatric surgery activity. The aim of this paper was to analyze the outcome of SARS-CoV-2-positive patients admitted to our department during the regional COVID-19 pandemic in North-Eastern Romania. We also evaluated the changes generated in our daily practice by the COVID-19 pandemic and the dynamic response to this major challenge.

PATIENT CONCERNS

The patients presented with symptoms related to their primary diagnosis: local pain and deformity in case of fractures; pain, swelling, and erythema in case of abscess; pain and decreased range of motion (ROM) in case of intolerance to metal implants. Other specific concerns are mentioned on an individual basis.

DIAGNOSES

Eighteen patients (of which 4 had acute appendicitis and were included in a previous article), representing 1.18% of the total number of admissions, tested positive for SARS-CoV-2. There were 4 patients with fractures, 3 patients with soft tissue abscess or cellulitis, 2 patients with intolerance to metal implants, 1 patient with facial burn, 1 patient with thumb laceration, 1 patient with liver trauma, 1 patient with undescende testis, and 1 patient with symptomatic inguinal hernia, respectively. Boys represented 11/ 14 (78.57%) of the cases. The mean age of the patients was 9 years 11 months. There were only mild COVID-19 cases.

INTERVENTIONS

Surgery was performed in 13/ 14 (95.71%) of cases. The fractures were treated with open reduction internal fixation (ORIF); incision and drainage (I & D) were performed in case of soft tissue abscess; the metal implants were removed in case of local intolerance. Other conditions (burn, inguinal hernia, undescended testis, skin laceration) were treated specifically. Only 1 patient with liver laceration was treated conservatively under close hemodynamic monitoring.

OUTCOMES

The mean length of stay (LoS) was 2.71 days. The infection with the SARS-CoV-2 virus had no deleterious effect on the surgical outcome among the 14 patients included in the study. There were no surgical complications during admission and no patient returned for late complications related to their primary disease or SARS-CoV-2 infection.

LESSONS

The SARS-CoV-2 infection had no significant influence on the outcome of pediatric surgical cases included in the study. We noticed a significant (31.54%) decrease in the number of admissions compared to the previous 2-year interval before the COVID-19 pandemic. Fast and adequate adjustment of the daily activity imposed by the COVID-19 pandemic was feasible and may be used in the future should similar epidemiological emergencies occur.

The impact of the COVID-19 pandemic on paediatric surgical volumes in Africa: A retrospective observational study

BACKGROUND

The aim of this study is to investigate the impact that COVID-19 had on the pattern and trend of surgical volumes, urgency and reason for surgery during the first 6 months of the pandemic in sub-Saharan Africa.

METHODS

This retrospective facility-based study involved collection of paediatric operation data from operating theatre records across 5 hospitals from 3 countries: Zimbabwe, Zambia and Nigeria over the first half of 2019 and 2020 for comparison. Data concerning diagnosis, procedure, anaesthesia, grade, speciality, NCEPOD classification and indication was collected. The respective dates of enactment of cancellation policies in each country were used to compare changes in weekly median surgical case volume before cancellation using the Wilcoxon Sign-Rank Test.

RESULTS

A total of 1821 procedures were recorded over the study period. Surgical volumes experienced a precipitous drop overall from a median of 100 cases/week to 50 cases/week coinciding with cancellation of surgical electives. Median accumulated weekly procedures before COVID-related cancellation were significantly different from those after cancellation (p = 0.027). Emergency surgery fell by 23.3% while electives fell by 78,9% (P = 0.042). The most common primary indication for surgery was injury which experienced a 30.5% drop in number of procedures, only exceeded by congenital surgery which dropped 34.7%.

CONCLUSIONS

The effects of surgical cancellations during the covid-19 pandemic are particularly devastating in African countries where the unmet need and surgical caseload are high. Continued cancellations that have since occurred will cause similar drops in surgical case volume that these health systems may not have the resilience to recover from.

LEVEL OF EVIDENCE

Level II.

Pediatric Surgical Reentry Strategy Following the COVID-19 Pandemic: A Tiered and Balanced Approach

BACKGROUND

In response to the COVID-19 pandemic, children's hospitals across the country postponed elective surgery beginning in March 2020. As projective curves flattened, administrators and surgeons sought to develop strategies to safely resume non-emergent surgery. This article reviews challenges and solutions specific to a children's hospital related to the resumption of elective pediatric surgeries. We present our tiered reentry approach for pediatric surgery as well as report early data for surgical volume and tracking COVID-19 cases during reentry.

METHODS

The experience of shutdown, protocol development, and early reentry of elective pediatric surgery are reported from Levine's Children's Hospital (LCH), a free-leaning children's hospital in Charlotte, North Carolina. Data reported were obtained from de-identified hospital databases.

RESULTS

Pediatric surgery experienced a dramatic decrease in case volumes at LCH during the shutdown, variable by specialty. A tiered and balanced reentry strategy was implemented with steady resumption of elective surgery following strict pre-procedural screening and testing. Early outcomes showed a steady thorough fluctuating increase in elective case volumes without evidence of a surgery-associated positive spread through periprocedural tracking.

CONCLUSION

Reentry of non-emergent pediatric surgical care requires unique considerations including the impact of COVID-19 on children, each children hospital structure and resources, and preventing undue delay in intervention for age- and disease-specific pediatric conditions. A carefully balanced strategy has been critical for safe reentry following the anticipated surge. Ongoing tracking of resource utilization, operative volumes, and testing results will remain vital as community spread continues to fluctuate across the country.

Peter SD, Fisher JC, Levy-Lambert D, Reichl A, Ignacio RC, Slater BJ, Tsao K, Berman L. Postoperative respiratory complications in SARS-CoV-2 positive pediatric patients across 20 United States hospitals: A Cohort Study

INTRODUCTION

Data examining rates of postoperative complications among SARS-CoV-2 positive children are limited. The purpose of this study was to evaluate the impact of symptomatic and asymptomatic SARS-CoV-2 positive status on postoperative respiratory outcomes for children.

METHODS

This retrospective cohort study included SARS-CoV-2 positive pediatric patients across 20 hospitals who underwent general anesthesia from March to October 2020. The primary outcome was frequency of postoperative respiratory complications, including: high-flow nasal cannula/non invasive ventilation, reintubation, pneumonia, Extracorporeal Membrane Oxygenation (ECMO), and 30-day respiratory-related readmissions or emergency department (ED) visits. Univariate analyses were used to evaluate associations between patient and procedure characteristics and stratified analyses by symptoms were performed examining incidence of complications.

RESULTS

Of 266 SARS-CoV-2 positive patients, 163 (61.7%) were male, and the median age was 10 years (interquartile range 4-14). The majority of procedures were emergent or urgent (n = 214, 80.5%). The most common procedures were appendectomies (n = 78, 29.3%) and fracture repairs (n = 40,15.0%). 13 patients (4.9%) had preoperative symptoms including cough or dyspnea. 26 patients (9.8%) had postoperative respiratory complications, including 15 requiring high-flow oxygen, 8 with pneumonia, 4 requiring non invasive ventilation, 3 respiratory ED visits, and 2 respiratory readmissions. Respiratory complications were more common among symptomatic patients than asymptomatic patients (30.8% vs. 8.7%, p = 0.01). Higher ASA class and comorbidities were also associated with postoperative respiratory complications.

CONCLUSIONS

Postoperative respiratory complications are less common in asymptomatic versus symptomatic SARS-COV-2 positive children. Relaxation of COVID-19-related restrictions for time-sensitive, non urgent procedures in selected asymptomatic patients may be reasonably considered. Additionally, further research is needed to evaluate the costs and benefits of routine testing for asymptomatic patients.

LEVEL OF EVIDENCE

Iii, Respiratory complications.

Challenges of the COVID-19 Pandemic for the Work–Family Balance of Pediatric Surgeons

The COVID-19 pandemic has been a great challenge, especially for families. We aimed to analyze the impact of the pandemic on childcare for and the work–family balance of pediatric surgeons in Germany. An anonymized questionnaire on the working and familial situation before and during the COVID-19 pandemic was sent to the members of the German Society of Pediatric Surgery and trainees in pediatric surgery (April–July 2021). One-hundred-fifty-three participants (59% female) completed the questionnaire. A total of 16% of the males and 62% of the females worked part-time. Most (68%) had underage children. During the COVID-19 pandemic, 36% reported a decrease in patients and interventions, and 55% reported an increase in the organizational work-related burden. Childcare for underage children during lockdown was organized mainly with the help of institutional emergency childcare (45%), staying home (34%), one parent working from a home office (33%), or staying home by themselves (34%). Before the lockdown, 54% reported a good work–family balance. During the lockdown, this worsened by 42%. Most of the families had to organize themselves. Different means such as a home office, flexible working hours, and different models for childcare can help to improve the situation.

Pediatric Residency Training amid the COVID-19 Pandemic: Exploring the Impact of Supervision and Clinical Practice Guidelines on Clinical and Financial Outcomes

Objective

This study is aimed at calculating the magnitude of the effect of clinical practice guidelines (CPG) and supervision in inhibiting the negative impact of the COVID-19 pandemic on clinical and financial outcomes of non-COVID-19 inpatient care by pediatric residents in academic medical center (AMC) hospitals during the COVID-19 pandemic.

Methods

The cohort retrospective study was conducted. This study collected patient data from pediatric residency programs. A research cohort consisted of non-COVID-19 pediatric patients at Dr. Soetomo General Academic Hospital. This study compared the subgroup of patients treated during the pandemic with those treated before the pandemic. The results were analyzed using SPSS 26.0 and Smart-PLS.

Results

There was a 41.4% decrease in pediatric inpatients during the pandemic with an increased severity level and complexity level, a reduction of 7.46% availability of supervisors, an increase of 0.4% in readmission < 30 days, an increase of 0.31% in-hospital mortality, an increase the total costs of care, and a decrease of insurance claim profit. CPG did not moderate the effect of the COVID-19 pandemic on the clinical outcomes (β = -0.006, P = 0.083) but moderated the financial outcomes (β = -0.022, P = 0.000), by reducing the total cost of care and increasing insurance claim profit. Supervision moderated the effect of the COVID-19 pandemic on the clinical outcomes (β = 0.040, P = 0.000) by increasing aLOS and on the financial outcomes (β = -0.031, P = 0.000) by reducing the total cost of care and increasing insurance claim profit. This study model had a 24.0% variance of explanatory power for clinical outcomes and 49.0% for financial outcomes. This study's structural model effectively predicted clinical outcomes (Q 2 = 0.238) and financial outcomes (Q 2 = 0.413).

Conclusion

Direct supervision inhibited the negative impact of the COVID-19 pandemic on both clinical and financial outcomes of non-COVID-19 inpatient care by pediatric residents, while CPG only inhibited the negative impact on financial outcomes. Implication of This Study. In a disaster, the availability of CPG and direct supervision makes AMC hospitals able to inhibit the negative impact of disasters on clinical and financial outcomes.

Ethical Issues Related to the COVID-19 Pandemic That Have Influenced Pediatric Surgery

The response of the health care system to pediatric surgical patients has been dramatically altered by the coronavirus disease 2019 pandemic. Such changes have affected children, families, and the clinicians who care for them. In this review, we highlight some of the ethical issues faced by pediatric surgical patients and pediatric surgeons during the coronavirus disease 2019 pandemic, including the transition to public health ethics, scarcity of resources, exacerbation of disparities, moral distress for pediatric surgeons, and shifting reliance on telemedicine and other remote means of communication. We discuss how these issues have prompted both favorable and unfavorable changes to the surgical care of children and consider which changes may have a lasting effect on pediatric surgery. [Pediatr Ann. 2022;51(8):e306-e310.].

Global Pediatric Surgery in the Era of COVID-19

There is a tremendous unmet need regarding the surgical care of children in low- and middle-income countries. The rapid spread of coronavirus disease 2019 (COVID-19), and the resultant redistribution of health care resources required to combat it, has created even more unique difficulties in the provision of safe, timely, and affordable surgical care of children globally. The downstream effects of potential diminished surgical capacity may even more significantly affect the morbidity and mortality of children. The full effects of these changes are yet to be seen. The COVID-19 pandemic has also created unique opportunities that can be built on moving forward. It is critical that the focus on global surgical needs, particularly for children, continues to be a priority to mitigate the challenges caused by the COVID-19 pandemic. [Pediatr Ann. 2022;51(8):e316-e318.].

Challenges in the management of paediatric surgical patients in the midst of COVID-19 crisis: Our experience

INTRODUCTION

As a result of the coronavirus disease (COVID-19) pandemic, more than 28 million planned surgeries worldwide could be cancelled leading to patients facing long waiting period for their treatment. The outbreak of COVID-19 caused by severe acute respiratory syndrome coronavirus (SARS CoV-2) has spread to more than 220 countries around the world and has almost stopped all routine surgical work. In children, the delay in the management of surgical diseases could result in significant morbidity and mortality.

MATERIAL AND METHOD

Herein, we describe our experience with the management of Paediatric Surgical patients at our centre which is a tertiary level hospital catering to both COVID-19 positive and Non-COVID patients in all specialties.

OBSERVATION AND RESULTS

During the COVID-19 pandemic, 69.41% fewer paediatric surgical patients underwent surgery relative to the corresponding period 1 year earlier. However, the number of emergency cases performed increased during the COVID pandemic by 62.12%, mostly involving, urological and gastrointestinal emergencies.

CONCLUSION

As we gain experience in effective protocol-based management, which can be revised based on the evolving scientific evidence. It will be appropriate to resume the elective work in selected patients, following the appropriate level of precautions.

The impact of the initial wave of COVID-19 pandemic on children under endoscopic esophageal dilatation protocol: a single center study

Purpose

COVID-19 pandemic has adversely affected the medical services offered for non-COVID related pathologies all over the world. This led to most of the elective services being postponed. In this study, we investigated the impact of the initial wave of COVID-19 pandemic on patients with esophageal strictures that were listed on the endoscopic dilatation program.

Methods

Medical records were reviewed from March–September 2020 (study group). The study period was divided into three intervals guided by the number of confirmed cases with COVID-19 and the measures taken during the lockdowns in the corresponding periods. Case burden, dilatation sessions, dysphagia score, and further interventions were reviewed. Case burden and dilatation sessions were compared to equivalent periods in 2019 (control group).

Results

The study group included 13 patients that had 19 dilatation sessions in contrast to 29 patients that had 98 sessions in the comparative group. In the study group, eight cases experienced deterioration in their dysphagia score, while further interventions were performed on four of them.

Conclusion

To avoid morbidities during the pandemic, high-risk patients should be precisely identified and actively followed. Parents and caregivers should be reassured and encouraged to seek medical advice as quickly as possible whenever the need arises.

Online action planning forums to develop a roadmap to mitigate the impact of COVID-19 on the delivery of global children’s surgical care

PURPOSE

We aimed to understand the challenges facing children's surgical care providers globally and realistic interventions to mitigate the catastrophic impact of COVID-19 on children's surgery.

METHODS

Two online Action Planning Forums (APFs) were organized by the Global Initiative for Children's Surgery (GICS) with a geographically diverse panel representing four children's surgical, anesthesia, and nursing subspecialties. Qualitative analysis was performed to identify codes, themes, and subthemes.

RESULTS

The most frequently reported challenges were delayed access to care for children; fear among the public and patients; unavailability of appropriate personal protective equipment (PPE); diversion of resources toward COVID-19 care; and interruption in student and trainee hands-on education. To address these challenges, panelists recommended human resource and funding support to minimize backlog; setting up international, multi-center studies for systematic data collection specifically for children; providing online educational opportunities for trainees and students in the form of large and small group discussions; developing best practice guidelines; and, most importantly, adapting solutions to local needs.

CONCLUSION

Identification of key challenges and interventions to mitigate the impact of the COVID-19 pandemic on global children's surgery via an objective, targeted needs assessment serves as an essential first step. Key interventions in these areas are underway.

Impact of the Global COVID-19 Pandemic on the Incidence, Presentation, and Management of Pediatric Appendicitis: Lessons Learned from the First Wave

The fast-evolving nature of the coronavirus disease 2019 (COVID-19) pandemic has led to unprecedented clinical, logistical, and socioeconomical challenges for health-care systems worldwide. While several studies have analyzed the impact on the presentation and management of acute appendicitis (AA) in the adult population, there is a relative paucity of similar research in pediatric patients with AA. To date, there is some evidence that the incidence of simple AA in children may have decreased during the first lockdown period in spring 2020, whereas the number of complicated AA cases remained unchanged or increased slightly. Despite a worrying trend toward delayed presentation, most pediatric patients with AA were treated expediently during this time with comparable outcomes to previous years. Hospitals must consider their individual capacity and medical resources when choosing between operative and non-operative management of children with AA. Testing for severe acute respiratory syndrome coronavirus type 2 is imperative in all pediatric patients presenting with fever and acute abdominal pain with diarrhea or vomiting, to differentiate between multisystem inflammatory syndrome and AA, thus avoiding unnecessary surgery. During the further extension of the COVID-19 crisis, parents should be encouraged to seek medical care with their children early in order that the appropriate treatment for AA can be undertaken in a timely fashion.

The COVID-19 pandemic impact on pediatric surgery residency programs

Background

The residency program as a part of the clinical services itself has been influenced by the COVID-19 outbreak. Several reports have been published regarding the impact of COVID-19 on the residency programs; however, all studies were performed in developed countries or did not comprehensively analyze what residents think about the COVID-19 impact on their residency program. We investigated the impact of the COVID-19 pandemic on the pediatric surgery residency program in our institution as an important part of hospital medical services.

Methods

We developed and distributed a questionnaire to pediatric surgery residents in our institution who were registered from January 2015-July 2020. The questionnaire was consisting of 24 questions: a) the perspectives of residents about COVID-19 infection during their residency program; b) the learning process; c) academic evaluations; and d) residents' suggestions to improve the quality of their residency program during the outbreak.

Results

Most (82.6%) pediatric surgery residents agreed that elective surgeries should be postponed during the pandemic. Before the outbreak, almost all (82.6%) residents used textbooks and journals as their primary sources of learning, while during the outbreak, 69.5% of residents shifted to use online lectures either from the school or Association of Pediatric Surgeons. Interestingly, 91.3% of participants agreed that they had more time to complete their academic assignments during the pandemic.

Conclusions

The pandemic has had a significant impact on the development of pediatric surgery residency programs. Moreover, the responses to the questionnaire are affected by the seniority and sex of the residents. A comprehensive approach is needed to maintain the high standard of competence of pediatric surgery without compromising our safety from the COVID-19 infection risk.

Exploring the impact of the COVID-19 pandemic on pediatric surgical services: a scoping review

Inevitably, along with other healthcare specializations, pediatric surgery was affected by the Coronavirus disease-19 (COVID-19) pandemic. Children were reported to manifest mild to moderate symptoms and mortality was primarily observed in patients aged <1 year and having underlying comorbidities. The majority of the cases were asymptomatic in children, hence, posing a challenge for pediatric surgery centers to take drastic measures to reduce the virus transmission. Telemedicine was introduced and outpatient consultations were conducted online as out-patient clinics were closed. Elective surgeries were postponed with delayed appointments while the healthcare sector was diverted towards tackling COVID-19. Case urgency was classified and triaged, leading to limited surgeries being performed only in COVID-19 negative patients following an extensive screening process. The screening process consisted of online history taking and RT-PCR tests. Newer practices such as mouth rinse, video laryngoscopy, and anesthesia were introduced to restrict patients from crying, coughing, and sneezing, as an attempt to avoid aerosolization of viral particles and safely conduct pediatric surgeries during the pandemic. Surgical trainees were also affected as the smaller number of surgeries conducted reduced the clinical experience available to medical enthusiasts. There is still room for advanced practices to be introduced in pediatric surgery, and restore all kinds of surgeries to improve the quality of life of the patient.

Impact of the COVID-19 pandemic on the surgical activity of Pediatric Urology: analysis of postoperative complications according to the Clavien-Dindo classification

Introducción y objetivo

La coronavirus disease 2019 (COVID-19) ha ocasionado una pandemia de repercusión mundial que obligó a tomar medidas sociopolíticas, como la declaración del estado de alarma en España. Paralelamente se llevó a cabo la reestructuración de las actividades e infraestructuras médico-quirúrgicas pediátricas, con la consecuente suspensión de la actividad quirúrgica no urgente de Urología Pediátrica. Analizamos la repercusión de la pandemia COVID-19 sobre la actividad quirúrgica en una sección de Urología Pediátrica, así como las complicaciones quirúrgicas, según la clasificación de Clavien-Dindo.

Materiales y métodos

Se procedió a la revisión sistemática de los datos epidemiológicos, clínicos y quirúrgicos, incluyendo las complicaciones y reingresos de todos los pacientes intervenidos en la sección de Urología Pediátrica desde la declaración del estado de alarma hasta el levantamiento del mismo. Para su estudio se procedió a la división en cinco bloques temporales acorde a las fases de desescalada.

Resultados

Se realizaron 49 intervenciones quirúrgicas en 45 pacientes (ocho previos a la implantación de las fases de desescalada). La patología con prioridad alta fue la más frecuente en las primeras fases, siendo la estenosis de la unión pieloureteral (EPU) la más prevalente. Se registraron cuatro complicaciones (8,8%), ninguna de ellas de origen respiratorio.

Conclusiones

Las recomendaciones de la EAU para la reanudación de la actividad quirúrgica han permitido una correcta, segura y gradual transición al ritmo quirúrgico habitual en Urología Pediátrica. La clasificación de Clavien-Dindo es útil y válida para su aplicación en esta sección. No se han registrados complicaciones respiratorias que pudiesen ser atribuibles a la situación pandémica.

Impact of the COVID-19 pandemic on the surgical activity of Pediatric Urology: analysis of postoperative complications according to the Clavien-Dindo classification

Introduction and objective

The "Coronavirus Disease 2019" (COVID-19) has caused a pandemic of global impact that forced social-political measures to be taken, such as the declaration of the state of alarm in Spain. At the same time, the reorganization of the pediatric medical-surgical activities and infrastructures was carried out, with the consequent suspension of the non-urgent surgical activity of Pediatric Urology. We analyzed the impact of the COVID-19 pandemic on surgical activity in a Pediatric Urology division, as well as surgical complications according to the Clavien-Dindo classification.

Materials and methods

A systematic review of epidemiological, clinical and surgical data was carried out, including complications and readmissions of all patients operated on in the division of Pediatric Urology within the duration of the state of alarm. Five time periods have been created according to the de-escalation phases.

Results

Forty-nine surgical procedures were carried out on 45 patients (8 prior to the implementation of the de-escalation phases). High priority pathologies were the most frequent in the first phases, being the ureteropelvic junction (UPJ) obstruction the most prevalent. Four complications were recorded (8.8%), none of them were respiratory.

Conclusions

The EAU recommendations for the resumption of surgical activity have allowed a correct, safe and gradual transition to the routine surgical activity in Pediatric Urology. The Clavien-Dindo classification is useful and valid for application in this division. No respiratory complications have been reported that could be attributable to the pandemic situation.

Challenges to delivering pediatric surgery services in the midst of COVID 19 crisis: experience from a tertiary care hospital of Pakistan

Covid-19 pandemic has significantly challenged the healthcare delivery across the world. Surgery departments across the country responded to this challenge by halting all non-emergency procedures. This delay in diagnosis and management of surgical disease could result in significant mortality and morbidity among the most vulnerable population-the children. In this manuscript, we discuss the measures adopted as well as the challenges faced by the pediatric surgery department at Aga Khan University Hospital, Karachi (AKUH), Pakistan, which is a private, not-for-profit entity and providing optimum surgical care to the patients. We also underscore the need for global strategies for tackling such crisis.

Impact of the COVID-19 pandemic on the surgical activity of Pediatric Urology: analysis of postoperative complications according to the Clavien-Dindo classification

INTRODUCTION AND OBJECTIVE

The coronavirus disease 2019 (COVID-19) has caused a pandemic of global impact that forced social-political measures to be taken, such as the declaration of the state of alarm in Spain. At the same time, the reorganization of the pediatric medical-surgical activities and infrastructures was carried out, with the consequent suspension of the non-urgent surgical activity of Pediatric Urology. We analyzed the impact of the COVID-19 pandemic on surgical activity in a Pediatric Urology division, as well as surgical complications according to the Clavien-Dindo classification.

MATERIALS AND METHODS

A systematic review of epidemiological, clinical and surgical data was carried out, including complications and readmissions of all patients operated on in the division of Pediatric Urology within the duration of the state of alarm. Five time periods have been created according to the de-escalation phases.

RESULTS

Forty-nine surgical procedures were carried out on 45 patients (8 prior to the implementation of the de-escalation phases). High priority pathologies were the most frequent in the first phases, being the ureteropelvic junction (UPJ) obstruction the most prevalent. Four complications were recorded (8.8%), none of them were respiratory.

CONCLUSIONS

The EAU recommendations for the resumption of surgical activity have allowed a correct, safe and gradual transition to the routine surgical activity in Pediatric Urology. The Clavien-Dindo classification is useful and valid for application in this division. No respiratory complications have been reported that could be attributable to the pandemic situation.

The Impact of COVID-19 pandemic on pediatric surgery practice: A cross-sectional study

Background

Since the COVID-19 pandemic was declared by the World Health Organization on March 11, 2020, routine clinical practices were affected, including pediatric surgery services. We aimed to compare pediatric surgery practices, including the number and types of surgery, either elective or emergency surgeries and outpatient services, before the outbreak and during the COVID-19 pandemic in our institution.

Material and methods

We retrospectively compared pediatric surgery practices, including elective and emergency surgeries, and outpatient services between the previous one-year period (March 2019–February 2020), the last three months of that period (December 2019–February 2020) before the outbreak, and the three months (March–May 2020) during the COVID-19 pandemic in our hospital.

Results

The frequency of elective surgeries during the pandemic was lower than during the last three months before the outbreak: 61 vs. 18 (~3-fold), 19 vs. 13 (~1.5-fold), 19 vs. 5 (~4-fold), and 30 vs. 15 (~2-fold) for digestive, neonate, urology and oncology cases, respectively. No laparoscopic procedures were performed during the pandemic compared with the one-year period before the outbreak (0 vs. 16 cases). The frequency of all emergency pediatric procedures before and during the COVID-19 pandemic was similar (29 vs. 20 cases, respectively). Moreover, a declining trend was also clearly apparent in the outpatient services during the pandemic compared with before the outbreak, both in the new and the established patients.

Conclusions

The pediatric surgery practices in our institution have been severely affected by the COVID-19 pandemic, including elective and outpatient services. This setback needs a comprehensive strategy to avoid morbidity from the neglected elective surgeries during the pandemic, including the proper comparison between the real risk of COVID-19 cross-infection and the benefits of elective procedures.

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Since the COVID-19 pandemic was declared by the World Health Organization on March 11, 2020, routine clinical practices were affected, including pediatric surgery services.

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The pediatric surgery practices have been severely affected by the COVID-19 pandemic, including the elective and outpatients' services.

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This setback needs a comprehensive strategy to avoid morbidity from the neglected elective surgeries during the pandemic, including the proper comparison between the real risk of COVID-19 cross-infection and the benefits of elective procedures.

Perspectives on perioperative management of children's surgical conditions during the COVID-19 pandemic in low-income and middle-income countries: a global survey

Background

Many organizations have issued recommendations to limit elective surgery during the coronavirus disease 2019 (COVID-19) pandemic. We surveyed providers of children's surgical care working in low-income and middle-income countries (LMICs) to understand their perspectives on surgical management in the wake of the COVID-19 pandemic and how they were subsequently modifying their surgical care practices.

Methods

A survey of children's surgery providers in LMICs was performed. Respondents reported how their perioperative practice had changed in response to COVID-19. They were also presented with 26 specific procedures and asked which of these procedures they were allowed to perform and which they felt they should be allowed to perform. Changes in surgical practice reported by respondents were analyzed thematically.

Results

A total of 132 responses were obtained from 120 unique institutions across 30 LMICs. 117/120 institutions (97.5%) had issued formal guidance on delaying or limiting elective children's surgical procedures. Facilities in LICs were less likely to have issued guidance on elective surgery compared with middle-income facilities (82% in LICs vs 99% in lower middle-income countries and 100% in upper middle-income countries, p=0.036). Although 122 (97%) providers believed cases should be limited during a global pandemic, there was no procedure where more than 61% of providers agreed cases should be delayed or canceled.

Conclusions

There is little consensus on which procedures should be limited or delayed among LMIC providers. Expansion of testing capacity and local, context-specific guidelines may be a better strategy than international consensus, given the disparities in availability of preoperative testing and the lack of consensus towards which procedures should be delayed.