Global children's surgery: recent advances and future directions

Gastrointestinal Ostomies in Children: A Primer for the Pediatrician

Despite the advancement of medical therapies in the care of the preterm neonate, in the management of short bowel syndrome and the control of pediatric inflammatory bowel disease, the need to create fecal ostomies remains a common, advantageous treatment option for many medically complex children.

A global view of pediatric urology

Over the course of approximately 60 years, the field of pediatric urology has evolved as a convergence of pediatric surgery, urology, and plastic surgery to address congenital anomalies of the urinary tract and genitalia in children. Guidelines for training and certification are narrowing in high-income countries (HICs) at the same time as the fertility rate is declining and the prevalence of complex genitourinary (GU) conditions is decreasing. In low-and middle-income countries (LMICs), health systems for large populations are currently in a state of stress. Here we briefly review the history of pediatric urology as a surgical subspecialty, identify unmet needs especially in LMICs and place the field in the context of a global surgical ecosystem.

METHODS

The English language literature on workforce trends in pediatric urology, pediatric surgery and urology was reviewed as well as development of the emerging field of global surgery. Global surgery looks at the social, economic and political context of health systems as well as unmet clinical need. World trends in fertility rates were reviewed to identify regions of workforce surplus and gaps, supply chain needs, infrastructure and systems strengths and weaknesses.

RESULTS

The proliferation of training programs in pediatric surgery and specialties in high-income countries (HICs) coupled with declining birth rates has led to a saturation of specialists and declining surgical case load. In LMICs, while the birth rate has also been declining, surgical specialization has not progressed. In the lowest income countries, especially in sub-Saharan Africa, training in pediatric surgical specialties and urology is rare. The broad workforce that supports surgical care, such as anesthesia, intensivist pediatrics, radiology, laboratory, and nursing face similar challenges. Supply chains for specialized pediatric urological surgery are weak.

CONCLUSION

There is an evolving maldistribution of pediatric surgical and pediatric urological workforce globally, with too few practitioners in LMICs and too many in HICs. The high cost of specialized equipment limits access to quality care, and the supply chain for consumables and medication is patchy. In LIC's, basic community-based infrastructure for health including reliable electricity is lacking. Recent experience with Covid and environmental disasters has highlighted that even in HICs surgical resilience can be challenged. This is an opportunity to consider the state of children's urological care globally and to build resilience by identifying and addressing strengths and gaps.

Age at Primary Cleft Lip Repair: A Potential Bellwether Indicator for Pediatric Surgery

The bellwether procedures described by the Lancet Commission on Global Surgery represent the ability to deliver adult surgical services after there is a clear and easily made diagnosis. There is a need for pediatric surgery bellwether indicators. A pediatric bellwether indicator would ideally be a routinely performed procedure, for a relatively common condition that, in itself, is rarely lethal at birth, but that should ideally be treated with surgery by a standard age. Additionally, the condition should be easy to diagnose, to minimize the confounding effects of delays or failures in diagnosis. In this study, we propose the age at primary cleft lip (CL) repair as a bellwether indicator for pediatric surgery.

Method

We reviewed the surgical records of 71,346 primary cleft surgery patients and ultimately studied age at CL repair in 40,179 patients from 73 countries, treated by Smile Train partners for 2019. Data from Smile Train's database were correlated with World Bank and WHO indicators.

Results

Countries with a higher average age at CL repair (delayed access to surgery) had higher maternal, infant, and child mortality rates as well as a greater risk of catastrophic health expenditure for surgery. There was also a negative correlation between delayed CL repair and specialist surgical workforce numbers, life expectancy, percentage of deliveries by C-section, total health expenditure per capita, and Lancet Commission on Global Surgery procedure rates.

Conclusion

These findings suggest that age at CL repair has potential to serve as a bellwether indicator for pediatric surgical capacity in Lower- and Middle-income Countries.

MicroRNA-1297 suppressed the Akt/GSK3 signaling pathway and stimulated neural apoptosis in an in vivo sevoflurane exposure model

Objective

Common inhalation anesthetics used for clinical anesthesia (such as sevoflurane) may induce nerve cell apoptosis during central nervous system development. Furthermore, anesthetics can produce cognitive impairments, such as learning and memory impairments, that continue into adulthood. However, the precise mechanism remains largely undefined. We aimed to determine the function of microRNA-1297 (miR-1297) in sevoflurane-induced neurotoxicity.

Methods

Reverse transcription-polymerase chain reaction assays were used to analyze miR-1297 expression in sevoflurane-exposed mice. MTT and lactate dehydrogenase (LDH) assays were used to measure cell growth, and neuronal apoptosis was analyzed using flow cytometry. Western blot analyses were used to measure PTEN, PI3K, Akt, and GSK3β protein expression.

Results

In sevoflurane-exposed mice, miR-1297 expression was up-regulated compared with the control group. MiR-1297 up-regulation led to neuronal apoptosis, inhibition of cell proliferation, and increased LDH activity in the in vitro model of sevoflurane exposure. MiR-1297 up-regulation also suppressed the Akt/GSK3β signaling pathway and induced PTEN protein expression in the in vitro model. PTEN inhibition (VO-Ohpic trihydrate) reduced PTEN protein expression and decreased the effects of miR-1297 down-regulation on neuronal apoptosis in the in vitro model.

Conclusion

Collectively, the results indicated that miR-1297 stimulates sevoflurane-induced neurotoxicity via the Akt/GSK3β signaling pathway by regulating PTEN expression.

Pediatric Orthopaedic Observerships in North America for International Surgeons: The Visitor's Perspective

BACKGROUND

There is substantial disparity in access to surgical care worldwide that largely impacts children in resource-limited environments. Although it has been suggested that surgeons in high-income countries work alongside their overseas peers to bridge this gap, there is limited information regarding the impact of pediatric orthopaedic observerships that are available to international surgeons. This study aimed to assess the perceived impact of such visitations on overseas surgeons, including their professional development and clinical practice.

METHODS

A survey was distributed to overseas surgeons who participated in a pediatric orthopaedic observership in North America in the years 2009 to 2019. Details were collected regarding each respondent's demographics and observership program, and the impact of this short-term clinical experience as perceived by the visiting surgeon.

RESULTS

Of the 181 international surgeons from 56 countries who participated in a pediatric orthopaedic observership, most were young male surgeons residing in a middle-income nation. The majority of surgeons observed in outpatient clinics (98%) and in the operating room (96%) and attended educational in-house conferences (92%). Most observers (75%) acknowledged gaining relevant orthopaedic knowledge and clinical skills that improved local patient care, and nearly all (99%) shared the newly acquired knowledge with their peers and trainees. Most (97%) were still living and working in the country that had been their residence at the time of their observership. No noteworthy trends were identified between the income classification of the surgeons' country of residence and their ability to incorporate the acquired skills into their practice.

CONCLUSIONS

Participating in a North American pediatric orthopaedic observership has a positive perceived impact on the majority of visiting surgeons, with potential gains in clinical skills and knowledge that likely benefit their patients, peers, and trainees. Such participation does not contribute to substantial brain drain and may assist with local capacity building. Identifying ways to increase access to such educational opportunities, particularly for surgeons from lower-income countries, should be explored further.

An Analysis of Essential Pediatric Surgical Cases Encountered During a Decade of Large-Scale Military Humanitarian Aid Missions

INTRODUCTION

Disease Control Priorities, 3rd Edition (DCP3) is an evidence-based, published resource that outlines essential procedures recommended for developing health care systems. These systems must consider various populations and the incidence of certain surgical conditions that require treatment. In relation to pediatric patients, the prevalence of certain surgical conditions encountered remains unclear in several low- and middle-income countries. Over the past 15 years, the USNS Mercy, one of the U.S. Navy's large hospital ships, has led the Pacific Partnership missions, which provide large-scale humanitarian aid throughout Southeast Asia. The data collected during these missions provide an opportunity to analyze the scope of pediatric operations performed in resource-limited countries. This analysis may assist in future planning for specific needs during military humanitarian missions.

MATERIALS AND METHODS

Surgical case data were prospectively collected during the six Pacific Partnership missions from 2006 to 2018. Demographic data were analyzed for all patients ≤8 years of age who underwent an operation. These data were retrospectively reviewed and all case logs were categorized by mission year, procedure-type, and host nation. Operations were classified based on 44 essential operations delineated in DCP3. Primary outcome was incidence of DCP3 essential operations. Secondary outcomes were perioperative complications. Standard statistical methods were performed for descriptive analysis.

RESULTS

A total of 3,209 major and minor operations were performed during 24 port visits in nine countries. Pediatric cases represented 1,117 (38%) of these procedures. Pediatric surgeons performed 291 (26%) of these cases. Based on DCP3 criteria, 789 pediatric operations (71%) were considered essential procedures. The most common DCP3-aligned procedures were cleft lip repair (432, 57%), hernia repair (207, 27%), and hydrocelectomy (60, 8%). Operative volume for pediatric surgery was highest during the 2008 mission (522 cases), when two pediatric surgeons were deployed, and lowest during the 2018 mission (five cases), when the mission focus was on education rather than surgical procedures and lack of pediatric cases referred by the host nation. Overall complication rate for pediatric cases was 1%.

CONCLUSIONS

This study represents the largest known analysis of military humanitarian assistance. Pediatric operations represented over one-third of the surgical volume during Pacific Partnership missions from 2006 to 2018. The majority of cases were DCP3-aligned and associated with a low complication rate. Future humanitarian aid missions and host nations should allocate appropriate medical and educational resources to treat DCP3 pediatric surgical diseases in low- and middle-income countries to support long-term capacity building while maintaining optimal surgical outcomes.

A systematic review of outcomes reported inpediatric perioperative research: A report from the Pediatric Perioperative Outcomes Group

The Pediatric Perioperative Outcomes Group (PPOG) is an international collaborative of clinical investigators and clinicians within the subspecialty of pediatric anesthesiology and perioperative care which aims to use COMET (Core Outcomes Measures in Effectiveness Trials) methodology to develop core outcome setsfor infants, children and young people that are tailored to the priorities of the pediatric surgical population.Focusing on four age-dependent patient subpopulations determined a priori for core outcome set development: i) neonates and former preterm infants (up to 60 weeks postmenstrual age); ii) infants (>60 weeks postmenstrual age - <1 year); iii) toddlers and school age children (>1-<13 years); and iv) adolescents (>13-<18 years), we conducted a systematic review of outcomes reported in perioperative studies that include participants within age-dependent pediatric subpopulations. Our review of pediatric perioperative controlled trials published from 2008 to 2018 identified 724 articles reporting 3192 outcome measures. The proportion of published trials and the most frequently reported outcomes varied across pre-determined age groups. Outcomes related to patient comfort, particularly pain and analgesic requirement, were the most frequent domain for infants, children and adolescents. Clinical indicators, particularly cardiorespiratory or medication-related adverse events, were the most common outcomes for neonates and infants < 60 weeks and were the second most frequent domain at all other ages. Neonates and infants <60 weeks of age were significantly under-represented in perioperative trials. Patient-centered outcomes, heath care utilization, and bleeding/transfusion related outcomes were less often reported. In most studies, outcomes were measured in the immediate perioperative period, with the duration often restricted to the post-anesthesia care unit or the first 24 postoperative hours. The outcomes identified with this systematic review will be combined with patient centered outcomes identified through a subsequent stakeholder engagement study to arrive at a core outcome set for each age-specific group.

Long term bowel function after repair of anorectal malformations in Uganda

BACKGROUND

Anorectal malformations (ARMs) are common congenital anomalies cared for at Mulago Pediatric Surgery Unit (PSU), similar to other sites in the region. All patients undergo staged repairs and complete treatment at older ages compared to high-income countries (HICs). This is the first study to examine long-term bowel function in our patients and compare with HICs.

METHODS

A retrospective cohort study was conducted of all children 3-12 years old with ARMs who had repair between January 2012 and June 2017 and who completed surgical repair at least 6 months prior to the study. Bowel function was measured using the fecal continence scoring system derived from Rintala and Lindahl (1995). As in prior studies, patients were classified by score into four categories: Poor (6-9); Fair (9-11); Good (12-17); and Normal (18-20).

RESULTS

Median follow up was 2 years post stoma closure. Long-term bowel function was Normal/Good in 65% (C.I 27, 45), and Fair/Poor 35% (C.I 55, 73), with soiling in 49% (C.I 40, 59), constipation in 23% (C.I 16, 32); and incontinence in 39% (C.I 30, 39). There was no statistically significant association between bowel function and multiple demographic, social, and clinical factors. Median age at completion of treatment (stoma reversal) was 2.3 years old, and median duration of colostomy (interval between stoma placement and takedown) was 1.8 years.

CONCLUSION

Despite definitive repair at older age and almost two years of living with a stoma, our patients achieve fair long-term bowel function. Nonetheless, improved follow up and timely management of complications may improve outcomes soiling, incontinence and constipation.

LEVEL OF EVIDENCE

Level II.