Globalization in Pediatric Surgical Training: The Benefit of an International Fellowship in a Low-to-Middle-Income Country Academic Hospital.

OBJECTIVE: A relative oversupply of pediatric surgeons led to increasing difficulties in surgical training in high-income countries (HIC), popularizing international fellowships in low-to-middle-income countries (LMIC). The aim of this study was to evaluate the benefit of an international fellowship in an LMIC for the training of pediatric surgery trainees from HICs. METHODS: We retrospectively reviewed and compared the prospectively maintained surgical logbooks of international pediatric surgical trainees who completed a fellowship at Chris Hani Baragwanath Academic Hospital in the last 10 years. We analyzed the number of surgeries, type of involvement, and level of supervision in the operations. Data are provided in mean differences between South Africa and the respective home country. RESULTS: Seven fellows were included. Operative experience was higher in South Africa in general (Δx̅ = 381; 95% confidence interval [CI]: 236-656; p < 0.0001) and index cases (Δx̅ = 178; 95% CI: 109-279; p < 0.0001). In South Africa, fellows performed more index cases unsupervised (Δx̅ = 71; 95% CI: 42-111; p < 0.0001), but a similar number under supervision (Δx̅ = -1; 95% CI: -25-24; p = 0.901). Fellows were exposed to more surgical procedures in each pediatric surgical subspecialty. CONCLUSION: An international fellowship in a high-volume subspecialized unit in an LMIC can be highly beneficial for HIC trainees, allowing exposure to higher caseload, opportunity to operate independently, and to receive a wider exposure to the different fields of pediatric surgery. The associated benefit for the local trainees is some reduction in their clinical responsibilities due to the additional workforce, providing them with the opportunity for protected academic and research time.

Regenerative capacity of the enteric nervous system: is immaturity defining the point of no return?

BACKGROUND: Intestinal obstruction in newborns is associated with intestinal motility disorders after surgery. Alterations in the enteric nervous system (ENS) might cause abnormal peristalsis, which may then result in intestinal motility disorders. We aimed to quantify alterations in the myenteric plexus after a ligation and to test if these alterations were reversible. METHODS: Small intestines of chicken embryos were ligated in ovo at embryonic day (ED) 11 for either 4 d (ED 11-15) or 8 d (ED 11-19). Both treated groups and control group were sacrificed and intestinal segments examined by means of both light and electron microscopy. RESULTS: The number of proximal myenteric ganglia increased (ED 19, 30.7 ± 3.16 versus 23.1 ± 2.03; P < 0.001) in the 8-d ligature group but had values similar to the control group in the 4-d ligature group. The size distribution was skewed toward small ganglia in the 8-d ligature group (ED 19, 83.71 ± 11.60% versus 3.88 ± 4.74% in the control group; P < 0.001) but comparable with the control group in the 4-d ligature group. Subcellular alterations in the 4-d ligature group were reversible. CONCLUSIONS: The pathologic alterations in the ENS were fully reversible in the 4-d ligature group. This reversibility might be linked to the degree of immaturity of the ENS.

High index of suspicion of intussusception in an 8-month South African child: a case report.

This case report describes diagnosis and management of intussusception in an 8-month-old baby girl seen at the Ventersdorp District Hospital, South Africa. According to the vaccination card, the child had been immunized with rotavirus vaccine with the last dose given 6 months and 2 weeks before presentation to Ventersdorp Hospital. This case of intussusception was unlikely associated with rotavirus vaccination.

A review of paediatric liver resections in Johannesburg: experiences and preferred technique.

BACKGROUND: Liver resections are widely performed in paediatric surgery. Many techniques exist to achieve vascular control, minimise bleeding and complete the parenchymal division. METHODS: We retrospectively reviewed all liver resections performed in the Department of Paediatric Surgery at our institution between January 2005 and June 2012. Data pertaining to basic demographics, indications for surgery, parenchymal transection techniques, morbidity, mortality and histology were collated. RESULTS: Twenty-one resections were performed in children aged 6 weeks - 11 years; 18 for malignant liver disease (including 9 hepatoblastomas), and 3 for benign disease. We describe 1 peri-operative mortality secondary to torsion of the liver remnant, and no surgical morbidity. Three cases underwent total hepatic vascular exclusion with sharp parenchymal transection. The remaining patients underwent selective vascular inflow and outflow control using the Cavitron Ultra Sonic Aspirator and Harmonic Scalpel to divide the parenchyma. CONCLUSION: Care for these patients should be multidisciplinary. High-volume units and access to liver transplantation offer optimal results. No technique is proven superior to the 'clamp crush' technique of parenchymal transection. Knowledge of hepatic anatomy is key to minimising morbidity, and surgeons should be familiar with and have the flexibility to use all techniques of vascular control.

Pediatric multifocal myofibroblastic tumors with involvement of the gallbladder: HIV- and Epstein-Barr virus-associated smooth muscle cell tumors.

Epstein-Barr virus associated smooth muscle cell tumors are commonly found in immunocompromised patients. These tumors occur most commonly in patients with AIDS and with greater incidence in children. The incidence of gallbladder tumors in these patients is rare, however. We report the case of a 10-year-old female patient who presented to our unit. She is HIV positive and on antiretroviral treatment. She required an emergency cholecystectomy to relieve external compression of the common bile duct where an empyematous gallbladder was found. Histopathology confirmed the presence of an Epstein-Barr virus-associated smooth muscle tumor. She is noted to have other asymptomatic lesions. Surgical intervention is reserved for symptomatic lesions and improves the immunocompromised state, although there is a propensity for local recurrence of the tumor.

Esophegeal replacement in children with AIDS.

We report 2 human immunodeficiency virus-positive patients with refractory esophageal strictures secondary to candidiasis. They presented with progressive dysphagia and had suffered from oropharyngeal and/or esophageal candidiasis within the preceding 3 months. Both failed conservative management of these strictures, including systemic antifungal therapy, administration of proton pump inhibitors, and numerous attempts at stricture dilation, ultimately progressing to open transhiatal esophagectomy. Although challenging in the immunocompromised host, successful treatment of these strictures by gastric interposition is achievable with minimal morbidity.