Outcomes after surgery for children in Africa (ASOS-Paeds): a 14-day prospective observational cohort study

BACKGROUND

Safe anaesthesia and surgery are a public health imperative. There are few data describing outcomes for children undergoing anaesthesia and surgery in Africa. We aimed to get robust epidemiological data to describe patient care and outcomes for children undergoing anaesthesia and surgery in hospitals in Africa.

METHODS

This study was a 14-day, international, prospective, observational cohort study of children (aged <18 years) undergoing surgery in Africa. We recruited as many hospitals as possible across all levels of care (first, second, and third) providing surgical treatment. Each hospital recruited all eligible children for a 14-day period commencing on the date chosen by each participating hospital within the study recruitment period from Jan 15 to Dec 23, 2022. Data were collected prospectively for consecutive patients on paper case record forms. The primary outcome was in-hospital postoperative complications within 30 days of surgery and the secondary outcome was in-hospital mortality within 30 days after surgery. We also collected hospital-level data describing equipment, facilities, and protocols available. This study is registered with ClinicalTrials.gov, NCT05061407.

FINDINGS

We recruited 8625 children from 249 hospitals in 31 African countries. The mean age was 6·1 (SD 4·9) years, with 5675 (66·0%) of 8600 children being male. Most children (6110 [71·2%] of 8579 patients) were from category 1 of the American Society of Anesthesiologists Physical Status score undergoing elective surgery (5325 [61·9%] of 8604 patients). Postoperative complications occurred in 1532 (18·0%) of 8515 children, predominated by infections (971 [11·4%] of 8538 children). Deaths occurred in 199 (2·3%) of 8596 patients, 169 (84·9%) of 199 patients following emergency surgeries. Deaths following postoperative complications occurred in 166 (10·8%) of 1530 complications. Operating rooms were reported as safe for anaesthesia and surgery for neonates (121 [54·3%] of 223 hospitals), infants (147 [65·9%] of 223 hospitals), and children younger than 6 years (188 [84·3%] of 223 hospitals).

INTERPRETATION

Outcomes following anaesthesia and surgery for children in Africa are poor, with complication rates up to four-fold higher (18% vs 4·4-14%) and mortality rates 11-fold higher than high-income countries in a crude, unadjusted comparison (23·15 deaths vs 2·18 deaths per 1000 children). To improve surgical outcomes for children in Africa, we need health system strengthening, provision of safe environments for anaesthesia and surgery, and strategies to address the high rate of failure to rescue.

FUNDING

Jan Pretorius Research Fund of the South African Society of Anaesthesiologists and Association of Anesthesiologists of Uganda.

Cutaneous fistulization: An extremely rare presentation of hydatid liver cyst in a child

We report the case of a 10-year-old child who presented with a renitent lesion on the left abdominal wall. Clinical, radiological, and intraoperative findings concluded to a cutaneous fistulization of a hydatid cyst of the left lobe of the liver. The diagnosis was confirmed by histopathological examination. The child was successfully treated with acombination of medical and surgical management. Complicated hydatid disease should be considered in the differential diagnoses of patients presenting with cutaneous fistulization, particularly in regions where hydatid disease is endemic.

A case report of multiple foreign body ingestion with a ring-like configuration: The magnetic effect

INTRODUCTION

Magnetic foreign body (FB) ingestion represents a significant health hazard among children. The increasing use of small attractive magnets as toys or parts of various household accessories makes it easily accessible to children. The aim of this report is to raise awareness of public authorities and parents around exposing children to magnetic toys.

CASE PRESENTATION

We report a case of multiple FB ingestion in a 3-year-old child. Radiological imaging revealed multiple round objects arranged in a circular shape resembling a ring. Surgical exploration showed multiple intestinal perforations attributed to the magnetic attraction between the objects.

CLINICAL DISCUSSION

Although more than 99 % of ingested FB pass without surgical intervention, ingestion of multiple magnetic FB provides a substantially higher risk of injury due to self-association and therefore requires a more aggressive clinical approach. A stable or clinically benign condition, though common, does not necessarily mean a safe situation in the abdomen. Literature review suggests that emergency surgical intervention should be pursued to avoid potentially life-threatening complications; perforation and peritonitis.

CONCLUSION

Multiple magnet ingestion is rare, but can result in serious complications. We recommend early surgical intervention before gastrointestinal complications develop.

[Acute gastric volvulus complicating congenital diaphragmatic hernia in a 3-month-old infant: a case report]

Gastric volvulus is a rare mode of revelation of congenital diaphragmatic hernia. This is an uncommon condition that may be difficult to diagnose in the paediatric population. We here report the case of a three-month-old infant presenting with a rapid worsening of acute dyspnoea. Chest X-ray showed image clarity and ascending gastric air sac. Thoraco-abdominal CT scan showed gastric volvulus complicating left congenital diaphragmatic hernia. Surgical treatment consisted of gastric devolvulation followed by complete reduction of the herniated viscera and closure of the diaphragmatic defect. Patient´s outcome was favourable. Congenital diaphragmatic hernia complicated by gastric volvulus should be considered as a diagnostic and therapeutic emergency due to the risk of life-threatening gastric necrosis.

Systematic review and meta-analysis efficacy and safety of immune checkpoint inhibitors in advanced melanoma patients with anti-PD-1 progression: a systematic review and meta-analysis

BACKGROUND

More than half of melanoma patients taking first-line anti-PD-1 therapy either express transient or no response at all. The efficacy and safety of secondary treatments for these patients are still not well established. Here, we evaluate the efficacy and safety of different melanoma FDA-approved ICI modalities used in post-anti-PD-1 refractory settings.

MATERIALS AND METHODS

We searched the PubMed database and the ASCO meetings library for studies on advanced melanoma patients with cancer progression on anti-PD-1 therapy and were then treated with ipilimumab, nivolumab/ipilimumab combination, or retreated with anti-PD-1. Primary and secondary endpoints were efficacy and toxicity, respectively. Pooled estimates for each treatment group were obtained using a random or fixed effects model according to detected heterogeneity.

RESULTS

Fourteen studies, of which 10 on ipilimumab, 2 on anti-PD-1 treatment, and 6 on combination therapies, were included, involving a total of 1460 patients. Twelve studies reported objective response rates (ORRs) and nine of them reported immune-related adverse events (irAEs). As for ORR, patients experienced a response that was inferior compared to the same therapy in treatment -naïve patients, with combination therapy having the best ORR of a pooled 23.08% (95% CI: 16.75% to 30.03%), followed by ipilimumab with a pooled ORR of 8.19% (95% CI: 5.78% to 10.92%). Survival data were also inferior in the ipilimumab cohort (mOS: 5.1 to 7.4 months) compared to ipilimumab in anti-PD-1 naive patients. As for grade 3/4 irAE occurrence, the ipilimumab cohort showed an estimate of 43.77% (95% CI 22.55% to 66.19%).

CONCLUSION

Our findings provide the best current evidence that patients who progress on anti-PD-1 can still respond to different ICI modalities (ipilimumab with or without nivolumab, and retreatment or continuation beyond progression with anti-PD-1) with tolerable grade 3/4 irAEs. However, more prospective clinical trials are needed to confirm these results.

Xeroderma pigmentosum and renal leiomyosarcoma: A very rare case report association

INTRODUCTION

Xeroderma pigmentosum (XP) is a rare genetic disorder causing extreme sensitivity to ultraviolet (UV) rays. It is transmitted by an autosomal recessive mode. This disease is classically characterized by a high risk of skin cancer. The occurrence of extra-dermatological cancers in patients followed for XP has been rarely reported in the literature. We present the case of a 14-year-old adolescent with an exceptional association of XP and renal leiomyosarcoma.

PRESENTATION OF CASE

A 14-year-old adolescent was presented with an abdominal mass revealed by hematuria and abdominal pain. Computed tomography (CT) of the abdomen showed an enhancing, heterogeneous right renal mass, consistent with the features of renal tumor. After non conclusive biopsy, a total nephrectomy of the right kidney was performed. Based on gross specimen observation and immunochemical analysis, the patient was diagnosed with high-grade renal leiomyosarcoma. An adjuvant chemotherapy was indicated and the patient was referred to medical oncology. At 12 months follow-up, the patient is in total remission; The CT scan did not show any locoregional or distant recurrence CONCLUSION: The risk of renal tumor is increased in patients followed for XP. Attending physicians should ask for renal imaging at the slightest sign of clinical call.

Congenital urethrocele in children. A case report

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This article proposes to discuss clinical, paraclinical and therapeutic characteristics of congenital urethrocele in children.

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We report a case of a 19-month-old child presenting with a penoscrotal mass.

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Diagnosis rests essentially on the micturating cystourethrography.

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Management of the lesion can be by endoscopic or open surgery. It depends on the size of the diverticulum and the degree of obstruction.

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An early, precise diagnosis and awareness of the anterior urethral diverticulum in boys with obstructive symptoms can reduce incidence of advanced uropathies.

Introduction

Congenital urethrocele is a rare disease in children. The diagnosis is often easy but the management remain difficult due to the risk of urethral stenosis form.

Case presentation

We report a case of a 19-month-old child presenting with a penoscrotal mass. Cystourethroscopy confirmed the diagnosis of an urethrocele of the anterior urethra.

Urethrocele repair was performed with good results.

We propose to discuss clinical, paraclinical and therapeutic characteristics of congenital urethrocele in children.

Conclusion

An early, precise diagnosis and awareness of the anterior urethral diverticulum in boys with obstructive symptoms can reduce incidence of advanced uropathies.

A rare case report of a neonatal idiopathic intussusception in a full-term newborn

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In contrast with the usual idiopathic intussusception appearing in infants, neonatal intussusception in full-term newborns is a very rare entity.

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It’s a challenging diagnosis since it has a misleading and variable presentation.

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Early diagnosis may be enhanced with abdominal ultrasonography that showed the classic target and pseudo kidney signs.

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An emergency laparotomy must be performed to confirm the ultrasound findings and to reduce the intussusception: Only way to save the patient.

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The overall prognosis for neonates with intussusceptions depends on early diagnosis, because once a critical condition develops, as in this case, the mortality rate is likely to rise.

Introduction

In contrast with the usual idiopathic intussusception appearing in infants, neonatal intussusception in full-term newborns is a rare entity and usually due to an organic lead point lesion. It has a misleading and variable presentation. This manuscript reports a very rare case of neonatal idiopathic intussusception in a full-term male newborn in order to highlight the difficulties in establishing an early diagnosis.

Presentation of case

We present a full-term male newborn who was referred to our department at day 7 of life with fecaloid vomiting, distended abdomen and absence of intestinal transit. No bloody stool was identified. The newborn was in poor condition, dehydrated and hypothermic. He was promptly resuscitated and an abdominal ultrasound was quickly performed, it showed an ileocecal intussusception located in the right hypochondriac region. An emergency laparotomy was performed confirming the ultrasound findings. The pathological exam of the resected bowel confirmed the presence of an intussusception with areas of hemorrhagic rearrangements but no lead point was detected. The patient died from septicemia.

Conclusion

Intussusception occurring in the neonate is still difficult to assess, because of its rarity and its uncommon mode of presentation. This case report underlines the importance to make early diagnosis, because once a critical condition develops, the mortality rate is likely to rise.

Uncommun etiology of pediatric Hematuria: urethral lymphangioma

We report a case of urethral cystic lymphangioma. Hematuria is the revealing symptom. Im our knowledge, is the third case described in literature.

Testicular tumours in prepubertal children: About eight cases

BACKGROUND

To analyze the spectrum of testicular tumors in prepubertal children and the therapeutic resultants in an unselected population.

MATERIALS AND METHODS

Our hospital database was analyzed for testicular tumors from January 1995 to December 2010 concerning clinical presentation, treatment and therapeutic results.

RESULTS

Eight patients were operated on because of testicular tumors. In six cases (75%) the tumor was benign: benign teratoma (four cases), epidermoid cyst (one case) and immature teratoma (one case). Two patients (25%) had a malignant tumour: yolk-sac tumour (two cases). All this children underwent surgery. Radical inguinal orchidectomy was performed in six cases and conservative surgery was performed in two cases. One patient has received adjuvant chemotherapy. Follow-up was uneventfully three years after primary surgery.

CONCLUSION

In prepubertal children, most testicular tumours are benign. If tumour markers were negative testis-preserving surgery can be proposed, complete excision of the tumour should be ascertained. In the case of testicular teratoma, the possibility of contralateral tumour should be considered in the follow-up.

Liver injuries in children: the role of selective non-operative management

BACKGROUND

Trauma remains the leading cause of mortality in the pediatric population. Liver injuries occur commonly in blunt abdominal trauma.

AIM

To assess the selective non-operative management of liver injuries in children.

METHODS

A retrospective review of 51 patients with a discharge diagnosis of traumatic liver injuries at Tunis Children's Hospital, over a 14-year period from 1996 to 2009.

RESULTS

We identified 51 patients with liver trauma. The median age was 7 years. Boys accounted for 58% (n= 30), and the most common cause was traffic accident. Head injuries were the most common associated injuries. Forty-nine patients (96%) required non-operative management without complications. The mean in-hospital stay was 10 days in this group. The ultrasound demonstrated complete resolution and healing after 3-6 months. Two patients underwent surgery for hemodynamic instability. The mortality rate was 0.2 %.

CONCLUSION

Safe, non-operative management involves careful serial examination, a CT scanning facility and close monitoring of the patient in a fully equipped high-dependency unit with trained staff to run it. Even though most patients can be treated non-operatively the challenge is to identify the severely injured child early and institute aggressive resuscitation and expedite laparotomy.

Management of perineal ectopic testes

BACKGROUND

Perineal ectopic testis (PET) is a rare congenital anomaly in which the testis is abnormally situated between the penoscrotal raphe and the genitofemoral fold.

AIM

we report six patients treated for PET. The epidemiological, clinical, radiological and therapeutic aspects of this rare entity are discussed in light of data of the literature.

RESULTS

Between 2000 and 2009, six patients (0, 2%) treated for PET were diagnosed among 2156 patients operated upon for undescended testes in unity of paediatric surgery in Tunis children's hospital. The mean age was 21+/- 25 months. The abnormality was associated with an inguinal hernia in two cases. The diagnosis was based on the presence of an empty scrotum or perineal swelling. In all, orchidopexy in a dartos pouch was easily performed through an inguinal skin crease incision.The length of the testicular vessels and vas deferens was adequate with a favourable course in every case. Although the complications of undescended testes are the same as for PET, the timing of surgery should be different.

CONCLUSION

It is generally accepted that children must not be below 6 months of age for surgical correction of undescended testes, but there is no need to delay surgery in PET, which can easily be diagnosed by physical examination in the neonatal period. Surgery is indicated even if there is no hernia present. The functional prognosis, always difficult to define, appears to be identical to that of other sites.

Field and laboratory testing in young elite soccer players

AIM

To determine if there are correlations between the physical fitness of young soccer players assessed by field and laboratory testing.

METHODS

Thirty four male soccer players took part in the study (mean (SD) age 17.5 (1.1) years, height 177.8 (6.7) cm, weight 70.5 (6.4) kg). Maximal oxygen uptake (VO(2)MAX) during treadmill running and vertical jump height on a force platform were measured in the laboratory. Field tests consisted of a soccer specific endurance test (Bangsbo test) and 30 m sprint with 10 m lap times.

RESULTS

The Bangsbo test correlated with the lowest velocity associated with VO(2)MAX (vVO(2)MAX; R(2) = 0.55, p<0.001), but not with VO(2)MAX. Sprint times at 30 m and 20 m were related to peak extension velocity and peak extension force measured during vertical jumping, but not to vertical jump height per se. The jumping force and velocity could explain 46% of the 30 m sprint performance (R(2) = 0.46, p<0.001).

CONCLUSION

The Bangsbo test and 30 m sprint test correlate with vVO(2)MAX and vertical jump force and velocity respectively. The Bangsbo test does not give a good estimate of VO(2)MAX in young soccer players.

Evaluation of the results of intraocular lens implantation in Egyptian children

A retrospective study was done for 95 eyes of Egyptian children in whom I.O.L. implantation was performed between 1985 and 1986 to treat unilateral cataract due to trauma or congenital or aphakia. The average range of follow up period was three to four years old. It was revealed that I.O.L. In traumatic cataract gave the best results (as regards the visual acuity with minimal complications) especially with anterior chamber lenses and still the secondary implantation of A.C. lenses had to some extent better results than that of primary A.C. lenses. In congenital cataract, P.C. lenses gave the worst results. Again, the older the age of the children, the better the results of I.O.L. implantation.