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Paediatric surgical outcomes in sub-Saharan Africa: a multicentre, international, prospective cohort study. BMJ Glob Health 2021; 6:bmjgh-2020-004406. [PMID: 34475022 PMCID: PMC8413881 DOI: 10.1136/bmjgh-2020-004406] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 01/23/2021] [Accepted: 01/26/2021] [Indexed: 11/03/2022] Open
Abstract
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.
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Seyi-Olajide JO, Ezidiegwu U, Ameh EA. Burden of Complicated Intra-Abdominal Infections in Children in Nigeria: Recent Experience and Systematic Review. Surg Infect (Larchmt) 2020; 21:501-508. [PMID: 32453672 DOI: 10.1089/sur.2020.118] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Affiliation(s)
- Justina Onyioza Seyi-Olajide
- Paediatric Surgery Unit, Department of Surgery, Lagos University Teaching Hospital, Idi-Araba, Lagos State, Nigeria
| | - Ugochukwu Ezidiegwu
- Division of Paediatric Surgery, Department of Surgery, National Hospital, Abuja, Nigeria
| | - Emmanuel Adoyi Ameh
- Division of Paediatric Surgery, Department of Surgery, National Hospital, Abuja, Nigeria
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Rickard J. Treating Surgical Infections in Low- and Middle-Income Countries: Source Control, Then What? Surg Infect (Larchmt) 2019; 20:192-196. [PMID: 30698510 DOI: 10.1089/sur.2018.125] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Surgical infections present a significant burden of disease globally. Management focuses on source control and appropriate antibiotic therapy. This remains a challenge in low- and middle-income settings, where access to surgical care and antibiotics is limited. This paper discusses the complex challenges facing the management of surgical infections in low- and middle-income countries.
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Affiliation(s)
- Jennifer Rickard
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota
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Jarnheimer A, Kantor G, Bickler S, Farmer P, Hagander L. Frequency of surgery and hospital admissions for communicable diseases in a high- and middle-income setting. Br J Surg 2015; 102:1142-9. [PMID: 26059635 DOI: 10.1002/bjs.9845] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Revised: 03/03/2015] [Accepted: 04/07/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND In high-income countries, non-communicable diseases drive the demand for surgical healthcare. Middle-income countries face a double disease burden, of both communicable and non-communicable disease. The aim of this study was to describe the role of surgery for the in-hospital care of infectious conditions in the high-income country Sweden and the middle-income country South Africa. METHODS A retrospective cohort study was performed of 1.4 million infectious disease admissions. The study populations were the entire population of Sweden, and a cohort of 3.5 million South Africans with private healthcare insurance, during a 7-year interval. The outcome measures were frequency of surgical procedures across a spectrum of diseases, and sex and age during the medical care event. RESULTS Some 8.1 per cent of Swedish and 15.7 per cent of South African hospital admissions were because of infectious disease. The proportion of infectious disease admissions that were associated with surgery was constant over time: 8.0 (95 per cent c.i. 7.9 to 8.1) per cent in Sweden and 21.1 (21.0 to 21.2) per cent in South Africa. The frequency of surgery was 2.6 (2.6 to 2.7) times greater in South Africa, and 2.2 (2.2 to 2.3) times higher after standardization for age, sex and disease category. CONCLUSION The study suggests that surgical care is required to manage patients with communicable diseases, even in high-income settings with efficient prevention and functional primary care. These results further stress the importance of scaling up functional surgical health systems in low- and middle-income countries, where the disease burden is distinguished by infectious disease.
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Affiliation(s)
- A Jarnheimer
- Department of Clinical Sciences in Lund, Paediatric Surgery and Global Paediatrics, Faculty of Medicine, Lund University, Lund, Sweden
| | - G Kantor
- Discovery Health, Sandton, and Department of Anaesthesiology, University of Cape Town, Cape Town, South Africa.,Department of Anesthesiology and Perioperative Medicine, University Hospitals Case Medical Center, Cleveland, Ohio, USA
| | - S Bickler
- Division of Paediatric Surgery, Rady Children's Hospital-University of California, San Diego, California, USA
| | - P Farmer
- Department of Global Health and Social Medicine, Harvard Medical School, Division of Global Health Equity, Brigham and Women's Hospital, and Partners In Health, Boston, Massachusetts, USA
| | - L Hagander
- Department of Clinical Sciences in Lund, Paediatric Surgery and Global Paediatrics, Faculty of Medicine, Lund University, Lund, Sweden
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Ibrahim M, Ladan MA, Abdussalam US, Getso KI, Mohammad MA, Chukwuemeka ALJ, Owolabi FL, Akhparov NN, Aipov RR. Open inguinal herniotomy: Analysis of variations. Afr J Paediatr Surg 2015; 12:131-5. [PMID: 26168752 PMCID: PMC4955417 DOI: 10.4103/0189-6725.160361] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Repair of congenital groin hernia/hydrocele is the most common surgical procedure performed by paediatric surgeons. There is dearth of literature comparing the outcomes of open herniotomy in children using various surgical approaches. This study was aimed at evaluating the efficacy of open herniotomy by comparing external ring incision, hernial sac twisting and whether or not double ligation has benefit over a single suture application. MATERIALS AND METHODS A multi-centre prospective randomised clinical trial was conducted with a total of 428 patients having congenital inguinal hernia and/or hydrocele. Patients were randomly assigned into four groups: RO (had external ring opened, hernial sac twisted and doubly ligated), ST (had hernial sac twisted and doubly ligated without opening the ring), DL (had double ligation of hernial sac without ring opening nor twisted) while SL (had single ligation of hernial sac with neither ring opening nor sac twisting). RESULTS A total of 458 repairs were done. Patients' age ranged from 0.25 years (3 months) to 21 years in group RO with mean of 4.87 × 4.07 (median, 4), 0.069 years (24 days) to 17 years in group ST with mean of 4.23 × 4.03 (median, 3), 0.5 years (6 months) to 16 years in group DL with mean of 4.59 × 3.87 (median, 4) and 1 year to 19 years in group SL with mean of 5.00 × 4.19 (median, 4). Operation time per repair was 26.50 × 5.46 min, range 16-40 min (median, 27 min) in group RO, 22.18 × 5.34 min, range 12-39 min (median, 21 min) in group ST while 17.98 × 3.40 min with range of 12-39 min (median, 17 min) in group DL and 15.27 × 4.18 min, range 7-40 min (median, 15 min) in group SL P < 0.0001. The mean paracetamol dose/patient was 3.96 × 1.43, 2.94 × 0.81, 2.18 × 0.69, 1.87 × 0.78 in group RO, ST, DL and SL, respectively, P < 0.0001. CONCLUSION Congenital inguinal hernia repair with opening of the external ring, hernia sac twisting and double ligation of the processus vaginalis confers no advantage.
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Affiliation(s)
- Musa Ibrahim
- Department of Surgery, Children Surgical Unit, Murtala Muhammad Specialist Hospital, Kano, Nigeria
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Conway JC, Taub PJ, Kling R, Oberoi K, Doucette J, Jabs EW. Ten-year experience of more than 35,000 orofacial clefts in Africa. BMC Pediatr 2015; 15:8. [PMID: 25884320 PMCID: PMC4342189 DOI: 10.1186/s12887-015-0328-5] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Accepted: 01/27/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Surgical correction of orofacial clefts greatly mitigates negative outcomes. However, access to reconstructive surgery is limited in developing countries. The present study reviews epidemiological data from a single charitable organization, Smile Train, with a database of surgical cases from 33 African countries from 2001-2011. METHODS Demographic and clinical patient data were collected from questionnaires completed by the participating surgeons. These data were recorded in Excel, analyzed using SPSS and compared with previously reported data. RESULTS Questionnaires were completed for 36,384 patients by 389 African surgeons. The distribution of clefts was: 34.44% clefts of the lip (CL), 58.87% clefts of the lip and palate (CLP), and 6.69% clefts of the palate only (CP). The male to female ratio was 1.46:1, and the unilateral: bilateral ratio 2.93:1, with left-sided predominance 1.69:1. Associated anomalies were found in 4.18% of patients. The most frequent surgeries included primary lip/nose repairs, unilateral (68.36%) and bilateral (11.84%). There was seasonal variation in the frequency of oral cleft births with the highest in January and lowest by December. The average age at surgery was 9.34 years and increased in countries with lower gross domestic products. The average hospital stay was 4.5 days. The reported complication rate was 1.92%. CONCLUSIONS With the exception of cleft palates, results follow trends of worldwide epidemiologic reports of 25% CL, 50% CLP, and 25% CP, 2:1 unilateral:bilateral and left:right ratios, and male predominance. Fewer than expected patients, especially females, presented with isolated cleft palates, suggesting that limitations in economic resources and cultural aesthetics of the obvious lip deformity may outweigh functional concerns and access to treatment for females. A fewer than expected associated anomalies suggests either true ethnic variation, or that more severely-affected patients are not presenting for treatment. The epidemiology of orofacial clefting in Africa has been difficult to assess due to the diversity of the continent and the considerable variation among study designs. The large sample size of the data collected provides a basis for further study of the epidemiology of orofacial clefting in Africa.
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Affiliation(s)
- Julia C Conway
- Department of Pediatrics at Icahn School of Medicine at Mount Sinai, One Gustave L Levy Place, Box 1497, New York, NY, 10029, USA.
| | - Peter J Taub
- Department of Pediatrics at Icahn School of Medicine at Mount Sinai, One Gustave L Levy Place, Box 1497, New York, NY, 10029, USA. .,Department of Surgery at Icahn School of Medicine at Mount Sinai, New York, NY, USA. .,Department of Dentistry at Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Rochelle Kling
- State University of New York Downstate Medical School, Brooklyn, NY, USA.
| | - Kurun Oberoi
- Johns Hopkins University Medical School, Baltimore, MD, USA.
| | - John Doucette
- Department of Preventive Medicine at Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Ethylin Wang Jabs
- Department of Pediatrics at Icahn School of Medicine at Mount Sinai, One Gustave L Levy Place, Box 1497, New York, NY, 10029, USA. .,Department of Genetics and Genomic Sciences at Icahn School of Medicine at Mount Sinai, New York, NY, USA. .,Developmental and Regenerative Biology at Icahn School of Medicine at Mount Sinai, New York, New York, USA, New York, NY, USA.
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Kendig CE, Samuel JC, Varela C, Msiska N, Kiser MM, McLean SE, Cairns BA, Charles AG. Pediatric surgical care in Lilongwe, Malawi: outcomes and opportunities for improvement. J Trop Pediatr 2014; 60:352-7. [PMID: 24771355 PMCID: PMC4271107 DOI: 10.1093/tropej/fmu026] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND One of the objectives of the Millennium Development Goals is to improve child health. We describe the burden of pediatric surgical disease at a tertiary hospital in Malawi. METHODS We conducted a retrospective analysis of a pediatric surgery database at Kamuzu Central Hospital in Malawi for the calendar year 2012. Variables included patient demographics, admission diagnosis, primary surgery and outcome. RESULTS A total of 1170 pediatric patients aged 0-17 years were admitted to the surgical service during the study period. The mean age was 6.9 years, and 62% were male. Trauma was the most common indication for admission (51%, n = 596), and 67% (n = 779) of all patients were managed non-operatively. Neonates and patients managed non-operatively had a significantly increased risk of mortality. CONCLUSION Only a third of patients admitted to the pediatric surgery service underwent surgery. More than half of patients with congenital anomalies did not undergo surgical intervention. Importantly, patients who underwent surgery had a survival advantage.
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Affiliation(s)
- Claire E. Kendig
- Department of Surgery, Division of Trauma and Critical Care Surgery, University of North Carolina, Chapel Hill, NC, USA,UNC Project, Lilongwe, Malawi
| | - Jonathan C. Samuel
- Department of Surgery, Division of Trauma and Critical Care Surgery, University of North Carolina, Chapel Hill, NC, USA,UNC Project, Lilongwe, Malawi
| | - Carlos Varela
- Department of Surgery, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Nelson Msiska
- Department of Surgery, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Michelle M. Kiser
- Department of Surgery, Division of Trauma and Critical Care Surgery, University of North Carolina, Chapel Hill, NC, USA
| | - Sean E. McLean
- Department of Surgery, Division of Pediatric Surgery, University of North Carolina, Chapel Hill, NC, USA
| | - Bruce A. Cairns
- Department of Surgery, Division of Trauma and Critical Care Surgery, University of North Carolina, Chapel Hill, NC, USA
| | - Anthony G. Charles
- Department of Surgery, Division of Trauma and Critical Care Surgery, University of North Carolina, Chapel Hill, NC, USA,UNC Project, Lilongwe, Malawi
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Petroze RT, Calland JF, Niyonkuru F, Groen RS, Kyamanywa P, Li Y, Guterbock TM, Rodgers BM, Rasmussen SK. Estimating pediatric surgical need in developing countries: a household survey in Rwanda. J Pediatr Surg 2014; 49:1092-8. [PMID: 24952795 DOI: 10.1016/j.jpedsurg.2014.01.059] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2013] [Revised: 01/25/2014] [Accepted: 01/28/2014] [Indexed: 11/16/2022]
Abstract
PURPOSE Surgical services for children are often absent in resource-limited settings. Identifying the prevalence of surgical disease at the community level is important for developing evidence-based pediatric surgical services and training. We hypothesize that the untreated surgical conditions in the pediatric population are largely uncharacterized and that such burden is significant and poorly understood. Furthermore, no such data exist at the population level to describe this population. METHODS We conducted a nationwide cross-sectional cluster-based population survey to estimate the magnitude of surgical disease in Rwanda. Conducted as a verbal questionnaire, questions included representative congenital, acquired, malignant and injury-related conditions. Pediatric responses were analyzed using descriptive statistics and univariate analysis. RESULTS A total of 1626 households (3175 individuals) were sampled with a 99% response rate; 51.1% of all individuals surveyed were younger than age 18. An estimated 50.5% of the total current surgical need occurs in children. Of all Rwandan children, 6.3% (95% CI 5.4%-7.4%), an estimated 341,164 individuals, were identified to have a potentially treatable surgical condition at the time of the interview. The geographic distribution of surgical conditions significantly differed between adults and children (p<0.001). CONCLUSIONS The results emphasize the magnitude of the pediatric surgery need as well as the need for improved education and resources. This may be useful in developing a collaborative local training program.
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Affiliation(s)
- Robin T Petroze
- Department of Surgery, University of Virginia School of Medicine, Charlottesville, VA, USA; Faculty of Medicine, University of Rwanda, Butare, Rwanda.
| | - J Forrest Calland
- Department of Surgery, University of Virginia School of Medicine, Charlottesville, VA, USA
| | | | - Reinou S Groen
- Department of Gynecology and Obstetrics, Johns Hopkins Hospital, Baltimore, MD, USA; Surgeons OverSeas (SOS), New York, NY, USA
| | | | - Yue Li
- Center for Survey Research & Department of Statistics, University of Virginia, Charlottesville, VA, USA
| | - Thomas M Guterbock
- Center for Survey Research & Department of Public Health Sciences, University of Virginia, Charlottesville, VA, USA
| | - Bradley M Rodgers
- Division of Pediatric Surgery, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Sara K Rasmussen
- Division of Pediatric Surgery, University of Virginia School of Medicine, Charlottesville, VA, USA
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