Evaluation of the regional distribution of the pediatric surgery workforce and surgical load in Brazil

Objective

The purpose of this study is to examine the regional distribution of the pediatric surgery workforce and the expected local demand for pediatric surgical procedures in Brazil.

Methods

We collected data on the pediatric surgical workforce, surgical volume, Gross Domestic Product per capita, and mortality for gastrointestinal tract malformations (MGITM) across the different regions of Brazil for 2019.

Results

Data from the Federal Medical Council reported 1515 pediatric surgery registries in Brazil, corresponding to 1414 pediatric surgeons (some pediatric surgeons are registered in more than one state), or 2.4 pediatric surgeons per 100 000 children 14 years of age and younger. There were 828 men and 586 women. The mean age was 51.5±12.8 years, and the mean time from graduation was 3.4±5.7 years. There is a higher concentration of pediatric surgeons in the wealthier Central-West, South, and Southeast regions. Individual surgical volume ranged from 88 to 245 operations/year (average 146 operations/year) depending on the region. Of these, only nine (6.1%) were high-complexity (including neonatal) operations. MGITM tended to be higher in the poorer North and Northeast regions than in other regions of Brazil.

Conclusions

Our findings suggest significant disparities in the surgical workforce and workload across Brazil related to socioeconomic status. Regions with an increased surgical workforce were associated with lower MGITM. The average number of complex operations performed annually by each pediatric surgeon was considerably low. Strategic investment and well-defined health policies are imperative to enhance the quality of surgical care in the different regions of Brazil.

Level of evidence

Retrospective review; level IV.

Monitoring intravesical pressure during gastroschisis closure. Does it help to decide between delayed primary or staged closure?

INTRODUCTION AND OBJECTIVE

Correction of gastroschisis may be accomplished by either primary or staged closure or even delayed primary closure after the use of a preformed silo. However, there is neither a consensus on the best approach nor established criteria to favor one method over the other. The aim of this paper was to investigate the role of intravesical pressure (IVP) as a tool to prevent abdominal compartment syndrome in newborns undergoing correction of abdominal wall defects.

METHODS

We retrospectively analyzed 45 newborns with gastroschisis in whom trans-operative intravesical pressure was used to choose between primary or staged closure. A threshold of 20 cm H(2)O was used and the outcomes between the two methods were compared.

RESULTS

In 24 children delayed primary closure was achieved while the remaining 21 underwent staged reduction and closure. There was no difference in the frequency of complications, time to begin oral feeding, length of parenteral nutrition or length of hospital stay between the children of the two groups. The incidence of temporary oliguria or anuria, averaged 33% and it was similar in both groups of children.

CONCLUSION

The data here presented suggests that monitoring intraoperative IVP during correction of gastroschisis may help to select children in whom staged closure is necessary, keeping their complication rate and overall outcome similar to that of children undergoing delayed primary closure. Further prospective studies should investigate more deeply the correlation between type of closure and the development of a compartment syndrome.

Alpha-fetoprotein following neonatal resection of sacrococcygeal teratoma

The sacrococcygeal teratoma (SCT) is the most frequent tumor in the neonatal period. Alpha-fetoprotein (AFP) levels fall after tumoral resection, although the time required for level normalization has not been established. The authors evaluate the time required for AFP levels to reach normal levels in 6 infants with prenatal diagnosis of SCT who underwent surgery for resection. The mean time required for AFP level normalization was 9 months. All patients were alive and 1 had neurogenic bladder. AFP has a progressive decrease, which may last 9 months in average and should not be confused with tumoral relapse.

Clinical and outcome characteristics of children with adrenocortical tumors: a report from the International Pediatric Adrenocortical Tumor Registry

PURPOSE

We created a registry for pediatric adrenocortical tumors (ACTs), which are rare and are not well characterized. We provide a descriptive analysis of 254 patients registered on the International Pediatric Adrenocortical Tumor Registry.

PATIENTS AND METHODS

Between January 1990 and December 2001, 254 patients younger than 20 years of age with newly diagnosed or previously treated ACTs were registered. A histologic diagnosis of ACT was required, although central review was not mandatory. Follow-up information was periodically requested from the referring physician. Treatment was chosen by the primary physician.

RESULTS

The overall female-male ratio was 1.6:1, but it varied widely among age groups. The most common presenting sign (84.2%) was virilization. Cushing's syndrome without virilization was uncommon (5.5%). Tumors were completely resected in 83% of patients. Patients with disseminated or residual disease received mitotane, cisplatin, etoposide, and/or doxorubicin, and rarely, radiation therapy. At a median follow-up of 2 years and 5 months, 157 patients (61.8%) survived without evidence of disease and 97 patients (38.2%) had died. The 5-year event-free survival estimate was 54.2% (95% CI, 48.2% to 60.2%). In a multivariate analysis, disease stage, presenting signs of endocrine dysfunction, and age were independently associated with prognosis.

CONCLUSION

Childhood ACTs occur predominantly in females and almost always causes clinical signs. Complete resection is required for cure. Residual or metastatic disease carries a poor prognosis. Our results demonstrate the feasibility of a disease-specific database for obtaining meaningful clinical and outcome information.

Selective surgical indication in the management of neutropenic children presenting with acute abdomen

As the treatment of pediatric malignancies improves and survival increases, the diagnosis of acute abdomen in these patients also becomes more common. Nevertheless, the management of this condition is still controversial. The authors report their experience in treating 12 neutropenic children with acute abdomen. The charts of 12 neutropenic patients with a diagnosis of acute abdomen treated at Boldrini Children's Cancer Center in Campinas, Brazil, between 1991 and 1996, were reviewed. Therapeutic strategy included an initial period of bowel rest, general supportive measures, and broad-spectrum antibiotics while waiting for the neutrophil count to rise. Three patients recovered completely without surgery, 8 underwent late surgery without complications, and 1 died due to uncontrolled sepsis before surgery. The treatment of acute abdomen in neutropenic children remains controversial. As shown in the present series, an initial nonoperative approach with selective surgical indication appears to be safe and to yield good results. Supportive treatment, until the neutrophil count rises, followed by surgery, if necessary, appears to be a sound therapeutic approach for neutropenic children with acute abdomen.

Epignathus: report of a case with successful outcome

Epignathus is an extremely rare form of teratoma that arises from the palate or pharynx in the region of the basisphenoid (Rathke's pouch). This condition is associated with a high mortality rate caused by severe airway obstruction in the neonatal period, thus requiring prenatal planning and prompt surgical treatment after birth. The authors describe a case of a giant epignathus that was successfully resected followed by an uneventful recovery.