RESUMO
PURPOSE: Intestinal obstruction caused by intestinal atresia is a surgical emergency in newborns. Outcomes for the jejunal ileal atresia (JIA), the most common subtype of atresia in low-income countries (LIC), are poor. We sought to assess the impact of utilizing the Bishop-Koop (BK) approach to JIA in improving outcomes. METHODS: A retrospective cohort study was performed on children with complex JIA (Type 2-4) treated at our national referral hospital from 1/2018 to 12/2022. BK was regularly used starting 1/1/2021, and outcomes between 1/2021 and 12/2022 were compared to those between 1/2018 and 12/2020. Statistical significance was set at p < 0.05. RESULTS: A total of 122 neonates presented with JIA in 1/2018-12/2022, 83 of whom were treated for complex JIA. A significant decrease (p = 0.03) was noted in patient mortality in 2021 and 2022 (n = 33, 45.5% mortality) compared to 2018-2020 (n = 35, 71.4% mortality). This translated to a risk reduction of 0.64 (95% CI 0.41-0.98) with the increased use of BK. CONCLUSION: Increased use of BK anastomoses with early enteral nutrition and decreased use of primary anastomosis improves outcomes for neonates with severe JIA in LIC settings. Implementing this surgical approach in LICs may help address the disparities in outcomes for children with JIA.
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Atresia Intestinal , Intestino Delgado/anormalidades , Recém-Nascido , Criança , Humanos , Atresia Intestinal/cirurgia , Estudos Retrospectivos , Íleo , JejunoRESUMO
INTRODUCTION: The incidence of pediatric Wilms' tumor (WT) is high in Africa, though patients abandon treatment after initial diagnosis. We sought to identify factors associated with WT treatment abandonment in Uganda. METHODS: A cohort study of patients < 18 years with WT in a Ugandan national referral hospital examined clinical and treatment outcomes data, comparing children whose families adhered to and abandoned treatment. Abandonment was defined as the inability to complete neoadjuvant chemotherapy and surgery for patients with unilateral WT and definitive chemotherapy for patients with bilateral WT. Patient factors were assessed via bivariate logistic regression. RESULTS: 137 WT patients were included from 2012 to 2017. The mean age was 3.9 years, 71% (n = 98) were stage III or higher. After diagnosis, 86% (n = 118) started neoadjuvant chemotherapy, 59% (n = 82) completed neoadjuvant therapy, and 55% (n = 75) adhered to treatment through surgery. Treatment abandonment was associated with poor chemotherapy response (odds ratio [OR] 4.70, 95% confidence interval [CI] 1.30-17.0) and tumor size > 25 cm (OR 2.67, 95% CI 1.05-6.81). CONCLUSIONS: Children with WT in Uganda frequently abandon care during neoadjuvant therapy, particularly those with large tumors with poor response. Further investigation into the factors that influence treatment abandonment and a deeper understanding of tumor biology are needed to improve treatment adherence of children with WT in Uganda.
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Neoplasias Renais , Terapia Neoadjuvante , Tumor de Wilms , Humanos , Uganda , Tumor de Wilms/terapia , Tumor de Wilms/cirurgia , Masculino , Feminino , Neoplasias Renais/terapia , Pré-Escolar , Criança , Terapia Neoadjuvante/estatística & dados numéricos , Lactente , Recusa do Paciente ao Tratamento/estatística & dados numéricos , Estudos Retrospectivos , Encaminhamento e Consulta/estatística & dados numéricos , Estudos de CoortesRESUMO
OBJECTIVE: The aim of this study was to empirically determine the optimal sample size needed to reliably estimate perioperative mortality (POMR) in different contexts. SUMMARY BACKGROUND DATA: POMR is a key metric for measuring the quality and safety of surgical systems and will need to be tracked as surgical care is scaled up globally. Continuous collection of outcomes for all surgical cases is not the standard in high-income countries and may not be necessary in low- and middle-income countries. METHODS: We created simulated datasets to determine the sampling frame needed to reach a given precision. We validated our findings using data collected at Mulago National Referral Hospital in Kampala, Uganda. We used these data to create a tool that can be used to determine the optimal sampling frame for a population based on POMR rate and target POMR improvement goal. RESULTS: Precision improved as the sampling frame increased. However, as POMR increased, lower sampling percentages were needed to achieve a given precision. A total of 357 eligible cases were identified in the Mulago database with an overall POMR rate of 14%. Precision of ±10% was achieved with 34% sampling, and precision of ±25% was obtained at 9% sampling. Using simulated datasets, a tool was created to determine the minimum sample percentage needed to detect a given mortality improvement goal. CONCLUSIONS: Reliably tracking POMR does not require continuous data collection. Data driven sampling strategies can be used to decrease the burden of data collection to track POMR in resource-constrained settings.
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Países em Desenvolvimento , Hospitais , Humanos , Uganda , Coleta de Dados , Bases de Dados FactuaisRESUMO
INTRODUCTION: Children's surgical access in low and low-middle income countries is severely limited. Investigations detailing met and unmet surgical access are necessary to inform appropriate resource allocation. MATERIALS AND METHODS: Surgical volume, outcomes, and distribution of pediatric general surgical procedures were analyzed using prospective pediatric surgical databases from four separate regional hospitals in Uganda. The current averted burden of surgical disease through pediatric surgical delivery in Uganda and the unmet surgical need based on estimates from high-income country data was calculated. RESULTS: A total of 8514 patients were treated at the four hospitals over a 6-year period corresponding to 1350 pediatric surgical cases per year in Uganda or six surgical cases per 100,000 children per year. The majority of complex congenital anomalies and surgical oncology cases were performed at Mulago and Mbarara Hospitals, which have dedicated pediatric surgical teams (P < 0.0001). The averted burden of pediatric surgical disease was 27,000 disability adjusted life years per year, which resulted in an economic benefit of approximately 23 million USD per year. However, the average case volume performed at the four regional hospitals currently represents 1% of the total projected pediatric surgical need. CONCLUSIONS: This investigation is one of the first to demonstrate the distribution of pediatric surgical procedures at a country level through the use of a prospective locally created database. Significant disease burden was averted by local pediatric and adult surgical teams, demonstrating the economic benefit of pediatric surgical care delivery. These findings support several ongoing strategies to increase pediatric surgical access in Uganda.
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Especialidades Cirúrgicas , Adulto , Humanos , Criança , Uganda/epidemiologia , Hospitais , Análise Custo-Benefício , Necessidades e Demandas de Serviços de SaúdeRESUMO
BACKGROUND: 1.7 billion of the world's 2.2 billion children do not have access to surgical care. COVID-19 acutely exacerbated this problem; delaying or preventing presentation and access to surgical care globally. We sought to quantify the effect of COVID-19 on children requiring surgery in Uganda. METHODS: Average monthly incident, elective pediatric surgical patient volume was calculated by sampling clinic logs before and during the pandemic, and case volume was quantified by reviewing operative logbooks for all surgeries in 2020 at Mulago Hospital, Kampala. Disability-Adjusted Life Years (DALYs) resulting from untreated disease were calculated and used to estimate economic impact using three different models. RESULTS: Expected elective pediatric surgery cases were 956. In 2020, pediatric surgery at Mulago was limited to 46 elective cases, approximately 5% of the expected incident cases, leading to a backlog of 910 patients and a loss of 10,620.12 DALYs. The economic impact of more than 10,000 disability years in Uganda is conservatively estimated at $23 million USD with other measures estimating ~ $120 million USD. CONCLUSION: The COVID-19 pandemic limited access to pediatric surgery in Uganda, making a chronic problem acutely worse, with costly consequences for the children and health system.
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COVID-19 , COVID-19/epidemiologia , Criança , Procedimentos Cirúrgicos Eletivos , Humanos , Pandemias/prevenção & controle , Atenção Terciária à Saúde , Uganda/epidemiologiaRESUMO
BACKGROUND: A popular paradigm to support surgical education for low- and middle-income countries (LMICs) is partnering with high-income country (HIC) surgeons. These relationships may, however, be asymmetric and fail to optimally address the most pressing curricular needs. We explored the effectiveness of our LMIC-HIC educational partnership. METHODS: Through a partnership between a HIC (Canada) and a LMIC (Uganda), three candidate surgeons were commissioned for a custom designed 1-year training experience at our HIC accredited pediatric surgical training centre as part of their overall formal education. The training curriculum was developed in collaboration with the LMIC pediatric surgeon and utilized competency-based medical education principles. A Likert and short-answer survey tool was administered to these trainees upon completion of their training. RESULTS: All prescribed milestones as well as specialty certification by examination of the College of Surgeons of East, Central and Southern Africa was achieved by participating fellows, each of whom have begun clinical practice, leadership and teaching roles in their home country. Although several obstacles were identified by fellows, all agreed that the experience boosted their clinical and teaching abilities, and was worth the effort. CONCLUSION: This endeavour in global pediatric surgical training represents a significant innovation in surgical education partnerships and would be reproducible across different surgical subspecialties and contexts. Such collaborative efforts represent a feasible upskilling opportunity towards addressing global surgical service capacity. LEVEL OF EVIDENCE: V.
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Países em Desenvolvimento , Cirurgiões , Criança , Humanos , Pobreza , Inquéritos e Questionários , UgandaRESUMO
Background. Despite favorable outcomes of laparoscopic surgery in high-income countries, its implementation in low- and middle-income countries (LMICs) is challenging given a shortage of consumable supplies, high cost, and risk of power outages. To overcome these barriers, we designed a mechanical retractor that provides vertical tension on the anterior abdominal wall. Methods. The retractor design is anatomically and mathematically optimized to provide exposure similar to traditional gas-based insufflation methods. Anatomical data from computed tomography scans were used to define retractor size. The retractor is constructed of biocompatible stainless steel rods and paired with a table-mounted lifting system to provide 5 degrees of freedom. Structural integrity was assessed through finite element analysis (FEA) and load testing. Functional testing was performed in a laparotomy model. Results. A user guide based on patient height and weight was created to customize retractor size, and 4 retractor sizes were constructed. FEA data using a 13.6 kg mass (15 mm Hg pneumoperitoneum) show a maximum of 30 mm displacement with no permanent deformation. Physical load testing with applied weight from 0 to 13.6 kg shows a maximum of 60 mm displacement, again without permanent deformation. Retraction achieved a 57% larger field of view compared to an unretracted state in a laparotomy model. Conclusions. The KeyLoop retractor maintains structural integrity, is easily sterilized, and can be readily manufactured, making it a viable alternative to traditional insufflation methods. For surgeons and patients in LMICs, the KeyLoop provides a means to increase access to laparoscopic surgery.
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Parede Abdominal , Insuflação , Laparoscopia , Cirurgiões , Parede Abdominal/cirurgia , Humanos , Laparoscopia/métodos , LaparotomiaRESUMO
OBJECTIVE: To determine the cost-effectiveness of building and maintaining a dedicated pediatric operating room (OR) in Uganda from the societal perspective. BACKGROUND: Despite the heavy burden of pediatric surgical disease in low-income countries, definitive treatment is limited as surgical infrastructure is inadequate to meet the need, leading to preventable morbidity and mortality in children. METHODS: In this economic model, we used a decision tree template to compare the intervention of a dedicated pediatric OR in Uganda for a year versus the absence of a pediatric OR. Costs were included from the government, charity, and patient perspectives. OR and ward case-log informed epidemiological and patient outcomes data, and measured cost per disability adjusted life year averted and cost per life saved. The incremental cost-effectiveness ratio (ICER) was calculated between the intervention and counterfactual scenario. Costs are reported in 2015 US$ and inflated by 5.5%. FINDINGS: In Uganda, the implementation of a dedicated pediatric OR has an ICER of $37.25 per disability adjusted life year averted or $3321 per life saved, compared with no existing operating room. The ICER is well below multiple cost-effectiveness thresholds including one times the country's gross domestic product per capita ($694). The ICER remained robust under 1-way and probabilistic sensitivity analyses. CONCLUSION: Our model ICER suggests that the construction and maintenance of a dedicated pediatric operating room in sub-Saharan Africa is very-cost effective if hospital space and personnel pre-exist to staff the facility. This supports infrastructure implementation for surgery in sub-Saharan Africa as a worthwhile investment.
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Salas Cirúrgicas/economia , Pediatria/economia , Saúde Pública/economia , Criança , Análise Custo-Benefício , Humanos , Modelos Econômicos , UgandaRESUMO
BACKGROUND: Laparoscopic surgery has become standard of care in high-income countries but is rarely accessible in low- and middle-income countries (LMICs). This study assessed experience with laparoscopy and attitudes toward a low-cost laparoscopic system among surgeons in sub-Saharan Africa. METHODS: A survey assessing current laparoscopic practice and feedback on a low-cost laparoscopic system was administered to attendees of the College of Surgeons of East, Central, and Southern Africa (COSECSA) Scientific Conference between December 4 and December 6, 2019 in Kampala, Uganda. RESULTS: Fifty-six surgeons from 14 countries participated. A majority were male (n = 46, 82%) general surgeons (n = 37, 66%) from tertiary/teaching hospitals (n = 36, 64%). For those with training in laparoscopy (n = 33, 59%), 22 (67%) reported less than 1 year of training and over half (n = 17, 52%) reported 1 month or less. Overall, a minority (n = 21, 38%) used laparoscopy in current practice, with 57% (n = 12) of those performing laparoscopy less than once per week. The most common laparoscopic surgeries performed were cholecystectomy (n = 15), diagnostic laparoscopy (n = 14), and appendectomy (n = 12). Few surgeons were performing more complex cases (n = 5). Barriers to laparoscopy included poor access to training equipment (n = 34, 61%), mentors (n = 33, 59%), laparoscopic equipment (n = 31, 55%), equipment maintenance (n = 25, 45%), access to consumable supplies (n = 21, 38%), and cost (n = 31, 55%). Fifty-two participants (93%) were interested in increasing their use of laparoscopy; the majority felt that a low-cost laparoscope (n = 52, 93%) and lift retractor for gasless laparoscopy (n = 46, 82%) would serve an unmet need in their practice. CONCLUSIONS: While the use of laparoscopy is currently limited in COSECSA countries, there is a significant interest among surgeons to increase implementation. A low-cost, durable laparoscopic system was viewed as a potential solution to the current barriers and could improve implementation in LMICs.
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Laparoscopia , Cirurgiões , África Austral , Atitude , Feminino , Humanos , Masculino , UgandaRESUMO
OBJECTIVE: This study aimed to assess health facilities' readiness to provide safe surgical care during Ebola and COVID-19 era in Uganda and in the Eastern DR Congo. METHODS: A cross-sectional study was conducted in selected national, regional referral and general hospital facilities in Uganda and in the eastern part of DR Congo from 1st August 2020 to 30th October 2020. Data was analysed using Stata version 15. RESULTS: The participation rate was of 37.5 % (72/192) for both countries. None of the hospitals fulfilled the readiness criteria for safe surgical care provision in both countries. The mean bed capacity of participating health facilities (HF) was 184 in Eastern DR Congo and 274 in Uganda with an average surgical ward bed capacity of 22.3 % (41/184) and 20.4 % (56/274) respectively. The mean number of operating rooms was 2 and 3 in Eastern DR Congo and Uganda respectively. Nine hospitals (12.5 %) reported being able to test for Ebola and 25 (34.7 %) being able to test for COVID-19. Postponing of elective surgeries was reported by 10 (13.9) participating hospitals. Only 7 (9.7 %) hospitals reported having a specific operating room for suspect or confirmed cases of Ebola or COVID-19. Appropriate Personal Protection Equipment (PPE) was reported to be available in 60 (83.3 %) hospitals. Most of the staff had appropriate training on donning and doffing of PPE 40 (55.6 %). Specific teams and protocols for safe surgical care provision were reported to be present in 61 (84.7 %) and 56 (77.8 %) respectively in Uganda and Eastern DR Congo participating hospitals. CONCLUSIONS: The lack of readiness to provide safe surgical care during Ebola and COVID-19 era across the participating hospitals in both countries indicate a need for strategies to enhance health facility supplies and readiness for safe surgical provision in resource-limited settings.
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COVID-19 , Doença pelo Vírus Ebola , Estudos Transversais , República Democrática do Congo/epidemiologia , Instalações de Saúde , Doença pelo Vírus Ebola/epidemiologia , Doença pelo Vírus Ebola/prevenção & controle , Humanos , SARS-CoV-2 , Uganda/epidemiologiaRESUMO
BACKGROUND: Ninety-four percent of congenital anomalies occur in low- and middle-income countries. In Uganda, only three pediatric surgeons and three pediatric anesthesiologists serve more than 20 million children. This study estimates burden, outcomes, coverage, and economic benefit of neonatal surgical conditions in Uganda. METHODS: A prospectively collected database was reviewed for neonatal surgical admissions from January 1, 2012, to December 31, 2017, at the only two sites with specialist pediatric surgical coverage. Outcomes were compared with high-income countries. Met and unmet need were estimated using disability-adjusted life years. Economic benefit was estimated using a value of statistical life-year approach. RESULTS: For 1313 neonatal admissions, the median age of presentation was 3 d, overall mortality was 36%, and median distance traveled was 40 km. Anorectal malformations were most common (18%). Postoperative mortality was 24%. Mortality was significantly associated with surgical intervention (P < 0.0001). Met need was 4181 disability-adjusted life years per year, which corresponds to a $3.5 million net economic benefit to Uganda, with a potential additional benefit of $153 million if unmet need were fully addressed. Approximately 2% of the total need is met by the health care system. CONCLUSIONS: Neonatal surgery is associated with improved survival for most conditions. Despite increases in workforce and infrastructure, a limited proportion of the need for neonatal surgery is currently being met. This is multifactorial, including lack of access to surgical care and severe shortages of workforce and infrastructure. Current and potential economic benefit to Uganda appears substantial.
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Efeitos Psicossociais da Doença , Necessidades e Demandas de Serviços de Saúde/estatística & dados numéricos , Hospitais Pediátricos/estatística & dados numéricos , Doenças do Recém-Nascido/cirurgia , Procedimentos Cirúrgicos Operatórios/estatística & dados numéricos , Análise Custo-Benefício , Feminino , Acessibilidade aos Serviços de Saúde/economia , Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , Necessidades e Demandas de Serviços de Saúde/economia , Mão de Obra em Saúde/economia , Mão de Obra em Saúde/estatística & dados numéricos , Mortalidade Hospitalar , Hospitais Pediátricos/economia , Humanos , Recém-Nascido , Doenças do Recém-Nascido/economia , Doenças do Recém-Nascido/epidemiologia , Masculino , Estudos Prospectivos , Anos de Vida Ajustados por Qualidade de Vida , Procedimentos Cirúrgicos Operatórios/economia , Taxa de Sobrevida , Uganda/epidemiologiaRESUMO
INTRODUCTION: The surgical workforce in sub-Saharan Africa is insufficient to meet population needs. Therefore, medical students should be encouraged to pursue surgical careers and "brain drain" must be minimized. It is unknown to what extent foreign aid priorities influence medical student career choices in Uganda. METHODS: Medical students in Uganda completed an online survey examining their career choices and attitudes regarding career opportunities and funding priorities. Data were analyzed using descriptive statistics, and responses among men and women were compared using Fisher's exact tests. RESULTS: Ninety-eight students participated. Students were most influenced by inspiring role models, employment opportunities and specialty fit with personal skills. Filling an underserved specialty was near the bottom of the influence scale. Women placed higher importance on advice from mentors (p = 0.049) and specialties with lower stress burden (p = 0.027). Men placed importance on opportunities in non-governmental organizations (p = 0.033) and academia (p = 0.050). Students expressed that the most supported specialties were infectious disease (n = 65, 66%), obstetrics (n = 15, 15%) and pediatrics (n = 7, 7%). Most students (n = 91, 93%) were planning a career in infectious disease. Fifty-three students (70%) indicated plans to leave Africa for residency. Female students were more likely to have a plan to leave (p = 0.027). CONCLUSION: Medical students in Uganda acknowledge the career opportunities for physicians in specialties prioritized by the Sustainable Development Goals. In order to avoid "brain drain" and encourage students to pursue careers in surgery, career opportunities including surgical residencies must be prioritized and supported in sub-Saharan Africa.
Assuntos
Escolha da Profissão , Mentores , Estudantes de Medicina/psicologia , Adulto , Criança , Feminino , Humanos , Masculino , Inquéritos e Questionários , UgandaRESUMO
BACKGROUND: We sought to understand the challenges in accessing pediatric surgical care in the context of the "three delays" model at the Pediatric Surgery Outpatient Clinic (PSOPC) at a tertiary hospital in Kampala, Uganda. MATERIALS AND METHODS: An outpatient database was established at the weekly PSOPC. A survey regarding prior healthcare visits and barriers to care was additionally administered to clinic patients and inpatients. RESULTS: Patients first sought healthcare a median of 56 d before the current visit to the PSOPC. A majority (52%) of patients first sought care at another health facility, and 17% of those surveyed had presented to the PSOPC three or more times for their current medical issue. Of 240 patients with a new issue or due for their next surgery, 10% were admitted to the ward, with only 54% receiving definitive care. Included in the most commonly needed surgeries for PSOPC patients were herniotomy (16% inguinal; 14.9% umbilical), orchiopexy (6.3%), posterior sagittal anorectoplasty (6.3%), and colostomy closure (4.4%), with the range of patient ages at the time of presentation reflecting delays in care. Patient expenditures associated with travel to the hospital showed inpatients coming from significantly further away, with higher costs of travel and need to borrow or sell assets to cover travel costs, when compared with PSOPC patients. CONCLUSIONS: Patients face significant delays in accessing and receiving definitive surgical care. Associated burdens associated with these delays place patients at risk for catastrophic health expenditures. Infrastructure and capacity development are necessary for improvement in pediatric surgical care.
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Gastos em Saúde/estatística & dados numéricos , Acessibilidade aos Serviços de Saúde/organização & administração , Necessidades e Demandas de Serviços de Saúde , Ambulatório Hospitalar/organização & administração , Procedimentos Cirúrgicos Operatórios/estatística & dados numéricos , Tempo para o Tratamento/organização & administração , Adolescente , Criança , Pré-Escolar , Feminino , Acessibilidade aos Serviços de Saúde/economia , Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , Hospitais Pediátricos/economia , Hospitais Pediátricos/organização & administração , Hospitais Pediátricos/estatística & dados numéricos , Humanos , Lactente , Recém-Nascido , Masculino , Ambulatório Hospitalar/economia , Ambulatório Hospitalar/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Estudos Prospectivos , Fatores Socioeconômicos , Procedimentos Cirúrgicos Operatórios/economia , Centros de Atenção Terciária/economia , Centros de Atenção Terciária/organização & administração , Centros de Atenção Terciária/estatística & dados numéricos , Tempo para o Tratamento/economia , Tempo para o Tratamento/estatística & dados numéricos , UgandaRESUMO
BACKGROUND: There is a significant unmet need for children's surgical care in low- and middle-income countries (LMICs). Multidisciplinary collaboration is required to advance the surgical and anesthesia care of children's surgical conditions such as congenital conditions, cancer and injuries. Nonetheless, there are limited examples of this process from LMICs. We describe the development and 3-year outcomes following a 2015 stakeholders' meeting in Uganda to catalyze multidisciplinary and multi-institutional collaboration. METHODS: The stakeholders' meeting was a daylong conference held in Kampala with local, regional and international collaborators in attendance. Multiple clinical specialties including surgical subspecialists, pediatric anesthesia, perioperative nursing, pediatric oncology and neonatology were represented. Key thematic areas including infrastructure, training and workforce retention, service delivery, and research and advocacy were addressed, and short-term objectives were agreed upon. We reported the 3-year outcomes following the meeting by thematic area. RESULTS: The Pediatric Surgical Foundation was developed following the meeting to formalize coordination between institutions. Through international collaborations, operating room capacity has increased. A pediatric general surgery fellowship has expanded at Mulago and Mbarara hospitals supplemented by an international fellowship in multiple disciplines. Coordinated outreach camps have continued to assist with training and service delivery in rural regional hospitals. CONCLUSION: Collaborations between disciplines, both within LMICs and with international partners, are required to advance children's surgery. The unification of stakeholders across clinical disciplines and institutional partnerships can facilitate increased children's surgical capacity. Such a process may prove useful in other LMICs with a wide range of children's surgery stakeholders.
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Anestesiologia , Serviços de Saúde da Criança , Comportamento Cooperativo , Especialidades Cirúrgicas , Anestesiologia/educação , Criança , Países em Desenvolvimento , Humanos , Especialidades Cirúrgicas/educação , UgandaRESUMO
In the original publication, the family name of one of the authors was spelt incorrectly. The correct name should read as Nensi Ruzgar.
RESUMO
INTRODUCTION/PURPOSE: The burden of pediatric surgical disease is largely unknown in low- and middle-income countries such as Uganda where access to care is limited. METHODS: Implementation of a locally led database in January 2012 at a Ugandan tertiary referral hospital, and review of 3465 prospectively collected pediatric surgical admissions from January 2012 to August 2016. RESULTS: 2090 children (60.3%) underwent surgery during admission. 59% were male and 41% female. 28.6% of admissions were in neonates and 50.4% were in children less than 1 year old. Congenital anomalies including Hirschsprung's, anorectal malformations, intestinal atresias, omphalocele, and gastroschisis were the most common diagnoses (38.6%) followed by infections (15.0%) and tumors (8.6%). Mortality rates were substantially higher than those of high-income countries; for example, gastroschisis and intussusception had mortality rates of 90.1% and 19.7%, respectively. Post-operative mortality was highest in the congenital anomalies group (15.0%). CONCLUSION: There is a high burden of infant congenital anomalies with higher mortality rates compared to high-income countries. The unit performs primarily specialized procedures appropriate for a tertiary center. We hope that these data will facilitate evaluation of ongoing quality improvement and capacity-building initiatives.
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Anormalidades Congênitas/epidemiologia , Infecções/epidemiologia , Neoplasias/epidemiologia , Ferimentos e Lesões/epidemiologia , Pré-Escolar , Anormalidades Congênitas/cirurgia , Feminino , Mortalidade Hospitalar , Hospitalização , Humanos , Lactente , Recém-Nascido , Infecções/cirurgia , Masculino , Neoplasias/cirurgia , Estudos Prospectivos , Centros de Atenção Terciária , Uganda/epidemiologia , Ferimentos e Lesões/cirurgiaRESUMO
BACKGROUND: Financial protection from catastrophic health care expenditure (CHE) and patient out-of-pocket (OOP) spending are key indicators for sustainable surgical delivery. We aimed to calculate these metrics for a hospital stay requiring surgery in Uganda's pediatric population. METHODS: A survey was administered to family members of postoperative patients in the pediatric surgical ward at Mulago Hospital. Cost categories included direct medical costs, direct nonmedical costs, indirect costs, plus money borrowed and items sold to pay for the hospital stay. CHE was defined as spending greater than 10% of annual household expenditure. Costs were reported in Ugandan shillings and US dollars. RESULTS: One hundred and thirty-two patient families were surveyed between November 2016 and April 2017. Median direct costs were $27.55 (IQR 18.73-183.69) for diagnostics, $18.36 (IQR 9.52-41.33) for medications, $26.63 (IQR 9.19-45.92) for transportation, and $32.60 (IQR 12.85-64.29) for food and lodging. Forty-four percent of respondents were employed, and median indirect cost from productivity loss was $95.52 (IQR 55.10-243.38). Eighteen percent (16/87) borrowed money, and 9% (8/87) sold possessions to pay for the hospital stay. Total median OOP cost for patient families per hospital stay was $150.62 (IQR 65.21-339.82). Sixteen percent (21/132) of families incurred CHE from direct costs, and the proportion rose to 27% (32/132) when indirect cost was included. CONCLUSIONS: Although pediatric surgical services in Uganda are formally provided for free by the public sector, families accrue substantial OOP expenditure and almost a third of households incur CHE for a pediatric surgical procedure. This study suggests that broader financial protection must be established to meet Sustainable Development Goal targets.
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Gastos em Saúde , Procedimentos Cirúrgicos Operatórios/economia , Pré-Escolar , Efeitos Psicossociais da Doença , Humanos , Tempo de Internação , PobrezaRESUMO
INTRODUCTION: Multiple pediatric surgical conditions require ostomies in low-middle-income countries. Delayed presentations increase the numbers of ostomies. Patients may live with an ostomy for a prolonged time due to the high backlog of cases with insufficient surgical capacity. In caring for these patients in Uganda, we frequently witnessed substantial socioeconomic impact of their surgical conditions. METHODS: The operative log at the only pediatric surgery referral center in Uganda was reviewed to assess the numbers of children receiving ostomies over a 3-year period. Charts for patients with anorectal malformations (ARM) and Hirschsprung's disease (HD) were reviewed to assess delays in accessing care. Focus group discussions (FGD) were held with family members of children with ostomies based on themes from discussions with the surgical and nursing teams. A pilot survey was developed based on these themes and administered to a sample of patients in the outpatient clinic. RESULTS: During the period of January 2012-December 2014, there was one specialty-certified pediatric surgeon in the country. There were 493 ostomies placed for ARM (n = 234), HD (N = 114), gangrenous ileocolic intussusception (n = 95) and typhoid-induced intestinal perforation (n = 50). Primary themes covered in the FGD were: stoma care, impact on caregiver income, community integration of the child, impact on family unit, and resources to assist families. Many patients with HD and ARM did not present for colostomy until after 1 year of life. None had access to formal ostomy bags. 15 caregivers completed the survey. 13 (86%) were mothers and 2 (13%) were fathers. Almost half of the caregivers (n = 7, 47%) stated that their spouse had left the family. 14 (93%) caregivers had to leave jobs to care for the stoma. 14 respondents (93%) reported that receiving advice from other caregivers was beneficial. CONCLUSION: The burden of pediatric surgical disease in sub-Saharan Africa is substantial with significant disparities compared to high-income countries. Significant socioeconomic complexity surrounds these conditions. While some solutions are being implemented, we are seeking resources to implement others. This data will inform the design of a more expansive survey of this patient population to better measure the socioeconomic impact of pediatric ostomies and guide more comprehensive advocacy and program development.
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Malformações Anorretais/cirurgia , Estomia/economia , Pobreza , Inquéritos e Questionários , Adolescente , Malformações Anorretais/economia , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Projetos Piloto , Fatores Socioeconômicos , UgandaRESUMO
Congenital abdominal wall defects occur when normal embryonic development is interrupted and most commonly results in gastroschisis or omphalocele. Other entities, such as ruptured omphalocele, vanishing gastroschisis, and patent omphalomesenteric ducts with prolapse, have also been described and can create a confusing picture. This case of a newborn with a midline abdominal defect and a mass that was intestine-like and arose from the bowel cannot be classified, and no similar reports were found. This suggests a previously undescribed abdominal wall defect with an aberrant colonic appendage.
Assuntos
Parede Abdominal/anormalidades , Hérnia Abdominal/patologia , Feminino , Humanos , Recém-NascidoRESUMO
BACKGROUND/AIM: Intestinal atresia is one of the leading causes of neonatal intestinal obstruction (NIO). The purpose of this study was to analyze the presentation and outcome of IA and compare with those from both similar and high-income country settings. PATIENTS AND METHODS: A retrospective review of prospectively collected data from patient charts and pediatric surgical database for 2012-2015 was performed. Epidemiological data and patient characteristics were analyzed and outcomes were compared with those reported in other LMICs and high-income countries (HICs). Unmet need was calculated along with economic valuation or economic burden of surgical disease. RESULTS: Of 98 patients, 42.9% were male. 35 patients had duodenal atresia (DA), 60 had jejunio-ileal atresia (JIA), and 3 had colonic atresia. The mean age at presentation was 7.14 days for DA and 6.7 days for JIA. Average weight for DA and JIA was 2.2 and 2.12 kg, respectively. All patients with DA and colonic atresia underwent surgery, and 88.3% of patients with JIA had surgery. Overall mortality was 43% with the majority of deaths attributable to aspiration, anastomotic leak, and sepsis. 3304 DALYs were calculated as met compared to 25,577 DALYs' unmet. CONCLUSION: Patients with IA in Uganda present late in the clinical course with high morbidity and mortality attributable to a combination of late presentation, poor nutrition status, surgical complications, and likely underreporting of associated anomalies rather than surgical morbidity alone. LEVEL OF EVIDENCE: Level IV, Case series with no comparison group.