Erratum to 'Exploring the cost-effectiveness of high versus low perioperative fraction of inspired oxygen in the prevention of surgical site infections among abdominal surgery patients in three low- and middle-income countries' [BJA Open 7 (2023) 100207].

[This corrects the article DOI: 10.1016/j.bjao.2023.100207.].

Erratum to "Exploring the cost-effectiveness of high versus low perioperative fraction of inspired oxygen in the prevention of surgical site infections among abdominal surgery patients in three low- and middle-income countries" [BJA Open 7 (2023) 100207].

[This corrects the article DOI: 10.1016/j.bjao.2023.100207.].

A Prospective Epidemiological Survey of Paediatric Trauma in Africa: A Cross-Sectional Study.

BACKGROUND: Trauma is a leading cause of morbidity and mortality in children worldwide. There is a need for development and provision of efficient paediatric trauma services based on adequate information and funding which are lacking in low- and middle-income countries. AIMS: This study was carried out to assess the scale of the problem, identify the most common causes of trauma in Pan African Paediatric Surgical Association (PAPSA) zone and to define the limiting factors for provision of the necessary services required to reduce the potential mortality and disability. MATERIALS AND METHODS: Data were collected through an electronic form sent out in PAPSA platform. Members were requested to provide prospective data on all paediatric major trauma admitted to or seen at their health facilities between the beginning of April 2019 and the end of June 2020. Hospital location, child's age, gender, type of injury, mechanism of injury, severity, initial management, method of transport, time to arrive to hospital, availability of surgical specialities, length of hospital stay and injury outcome were analysed. RESULTS: There were 531 entries. The mean age was 3.53 years and median age 1.34 years. Male-to-female ratio was 2:1. The leading causes for injuries were falls 194 (36.53%) and motor vehicle crashes (MVCs) 176 (33.15%) followed by obstetrical 42 (7.9%), thermal 27 (5.1%) and domestic injuries 22 (4.1%). The most common injuries were limb fractures 181 (34.1%) and traumatic brain injury 111 (20.9%). Public and private transport were used in 313 (58.9%), while ambulance service was used in only 54 (10.1%). Distances to a health facility varied between 1 and 157 km. 70.2% of cases did not receive any primary care, while definitive care was received in 95.5% of the cases. Outcome was full recovery in 90.6% of patients, morbidity in 8.1% and a mortality rate of 1.3%. CONCLUSIONS: Most of the injuries were in the under 5-year age group. The two main causes of trauma in children in this study were the falls from height and MVCs. Long distance travels to reach health-care facilities were noticeable in this study, together with substantial lack of adequate ambulance facilities and shortage in necessary subspecialty services such as neurosurgical, orthopaedics and rehabilitation. Implementing proposed recommendations can reduce the burden.

Academic global surgical competencies: A modified Delphi consensus study.

Academic global surgery is a rapidly growing field that aims to improve access to safe surgical care worldwide. However, no universally accepted competencies exist to inform this developing field. A consensus-based approach, with input from a diverse group of experts, is needed to identify essential competencies that will lead to standardization in this field. A task force was set up using snowball sampling to recruit a broad group of content and context experts in global surgical and perioperative care. A draft set of competencies was revised through the modified Delphi process with two rounds of anonymous input. A threshold of 80% consensus was used to determine whether a competency or sub-competency learning objective was relevant to the skillset needed within academic global surgery and perioperative care. A diverse task force recruited experts from 22 countries to participate in both rounds of the Delphi process. Of the n = 59 respondents completing both rounds of iterative polling, 63% were from low- or middle-income countries. After two rounds of anonymous feedback, participants reached consensus on nine core competencies and 31 sub-competency objectives. The greatest consensus pertained to competency in ethics and professionalism in global surgery (100%) with emphasis on justice, equity, and decolonization across multiple competencies. This Delphi process, with input from experts worldwide, identified nine competencies which can be used to develop standardized academic global surgery and perioperative care curricula worldwide. Further work needs to be done to validate these competencies and establish assessments to ensure that they are taught effectively.

Preputial cyst in the newborn: A case report from Africa.

Cysts of the prepuce are rare, and documented reports from the English literature are mostly from Asia. Presentations in children are worrisome to the parents. We report a case of a preputial cyst occurring in a neonate who was brought to our facility due to parental anxiety. After a thorough clinical evaluation, a freehand circumcision technique was performed which allowed exposure of the full extent of the cyst, the external urethral meatus and the glans, thus ensuring complete excision and minimising the risk of injury to the adjoining structures. We postulate that preputial cysts are rare in Africa due to the universality of circumcision, which is one of the options of treatment. Preputial cysts are benign foreskin cystic lesions that can be effectively treated with circumcision. This is probably the first reported case of a benign epithelioid preputial cyst from Africa. The paucity of reported cases may be due to the universal practice of circumcision in most of Africa.

Impact of corona virus disease 2019 pandemic on paediatric surgery in a sub-saharan tertiary hospital: An observational study.

Background: The impact of the corona virus disease 2019 (COVID-19) pandemic on global health, has reached far beyond that caused by the disease itself. With ongoing mutations and the emergence of new strains of the virus alongside repeated waves of the pandemic, the full impact of the pandemic is still evolving and remains difficult to predict or evaluate. In paediatric surgery, it has led to significant disruptions in patient care, the extent and consequence of which are not fully documented in Nigeria. Aim: This study aims to evaluate the impact of COVID-19 on services, training and research in a busy paediatric surgery unit during the initial 3-month period of the COVID-19 pandemic lockdown. Methods: This study was an ambispective evaluation of the preceding 3 months before lockdown and the initial 3 months of lockdown. Clinic cancellations, elective and emergency surgeries, delays in access, extra cost of care to patients, impact on training and research, and the psychologic impact of the pandemic on staff and guardians were evaluated. Results: During the 3-month lockdown period, an estimated 78 new cases and 637 follow-up cases could not access care. Ninety-seven elective surgeries in 91 patients were postponed. Two (2.2%) patients' symptoms progressed. All emergency patients received care. Out-of-pocket expenditure increased averagely by $124. The pandemic contributed to delays in seeking (13%), reaching (20%) and receiving care (6%). Trainee participation in surgeries was reduced and academic programmes were suspended. Five staff were exposed to the virus and 3 infected. Conclusion: Paediatric surgery has been negatively impacted by COVID-19. Efforts must focus on planning and implementing interventions to mitigate the long-term impact.

A 5-year multidisciplinary care outcomes in children with wilms' tumour managed at a tertiary centre: A retrospective observational study.

BACKGROUND: Over the last two decades, there has been significant improvement in the outcomes of children with Wilms' tumour (WT) in high income countries (HICs) with approximately 85% survival rate globally. This is partly attributable to a multi-disciplinary team approach to care and the evolution of more robust treatment measures. A previous review in our centre prior to multi-disciplinary team shows a survival rate of 31.48%, However, the survival rates from low- and middle-income countries are still low when compared to HICs due to delays in access to care at all levels, poor to non-existent health insurance coverage, limited workforce resources, weak health-care systems and infrastructure. The aim of this study is to determine the impact of a multi-disciplinary team approach on the treatment outcomes of children with WT. METHODOLOGY: This is a 5-year retrospective review of all patients managed with WT at the Lagos University Teaching Hospital, Lagos, Nigeria. Information was extracted from the patients' case notes, operation notes and ward admission records. The data were analysed with SPSS 25, and P < 0.05 was considered to be statistically significant. RESULTS: Forty patients were included in the study; male to female ratio was 1.6:1. The disease occurred in the right kidney in 23 patients (57.5%) and on the left in 17 patients (42.5%). The average duration of symptoms before presentation was 3.6 months (range 1-7 months), majority of patients presented with abdominal masses and were assessed as per unit protocol with abdominal Computerized tomography scan, chest X-ray and abdominal ultrasound scan to assign the patient International Society of Paediatric oncology regimen. The predominant stage at surgery was Stage III 26 (65%), while Stage IV was 9 (22.5%). Morbidity after chemotherapy was 10 (25%). Twenty-five patients (63%) completed chemotherapy while 15 patients (37%) started chemotherapy but defaulted midway. The 5-year survival rate was 75%. Increasing age and male sex were associated with reduced odds of mortality; however, this was not statistically significant. Increased duration of treatment, being treated with chemotherapy alone, as well as advanced tumour stage and histology were associated with increased odds of mortality, however, this was not statistically significant. CONCLUSION: The development of an institutional WT treatment pathway involving a multidisciplinary team has resulted in improved outcomes. There is need for increased community awareness to improve the time to presentation.

Preliminary model assessing the cost-effectiveness of preoperative chlorhexidine mouthwash at reducing postoperative pneumonia among abdominal surgery patients in South Africa.

BACKGROUND: Pneumonia is a common and severe complication of abdominal surgery, it is associated with increased length of hospital stay, healthcare costs, and mortality. Further, pulmonary complication rates have risen during the SARS-CoV-2 pandemic. This study explored the potential cost-effectiveness of administering preoperative chlorhexidine mouthwash versus no-mouthwash at reducing postoperative pneumonia among abdominal surgery patients. METHODS: A decision analytic model taking the South African healthcare provider perspective was constructed to compare costs and benefits of mouthwash versus no-mouthwash-surgery at 30 days after abdominal surgery. We assumed two scenarios: (i) the absence of COVID-19; (ii) the presence of COVID-19. Input parameters were collected from published literature including prospective cohort studies and expert opinion. Effectiveness was measured as proportion of pneumonia patients. Deterministic and probabilistic sensitivity analyses were performed to assess the impact of parameter uncertainties. The results of the probabilistic sensitivity analysis were presented using cost-effectiveness planes and cost-effectiveness acceptability curves. RESULTS: In the absence of COVID-19, mouthwash had lower average costs compared to no-mouthwash-surgery, $3,675 (R 63,770) versus $3,958 (R 68,683), and lower proportion of pneumonia patients, 0.029 versus 0.042 (dominance of mouthwash intervention). In the presence of COVID-19, the increase in pneumonia rate due to COVID-19, made mouthwash more dominant as it was more beneficial to reduce pneumonia patients through administering mouthwash. The cost-effectiveness acceptability curves shown that mouthwash surgery is likely to be cost-effective between $0 (R0) and $15,000 (R 260,220) willingness to pay thresholds. CONCLUSIONS: Both the absence and presence of SARS-CoV-2, mouthwash is likely to be cost saving intervention for reducing pneumonia after abdominal surgery. However, the available evidence for the effectiveness of mouthwash was extrapolated from cardiac surgery; there is now an urgent need for a robust clinical trial on the intervention on non-cardiac surgery.

Identifying a Basket of Surgical Procedures to Standardize Global Surgical Metrics: An International Delphi Study.

OBJECTIVE: We aimed to define a globally applicable list of surgical procedures, or "basket," which could represent a health system's capacity to provide surgical care and standardize global surgical measurement. SUMMARY OF BACKGROUND DATA: Six indicators have been proposed to assess access to safe, affordable, timely surgical and anesthesia care, with a focus on laparotomy, cesarean section, and treatment of open fracture. However, comparability, particularly for these procedures, has been limited by a lack of definitional clarity and their overly broad scope. METHODS: We conducted a 3 round international expert Delphi exercise between April and June 2019 using REDCap to identify a set of procedures representative of surgical capacity. To be included, procedures had to be important for treating common conditions, well-defined, and impactful (ie, well-recognized clinical or functional benefit). Procedures were eliminated or prioritized in each round, and those noted as "extremely" or "very important" by ≥50% of respondents in round 3 were included in the final "basket." RESULTS: Altogether 331 respondents from 78 countries participated in the Delphi process. A final basket of 32 procedures representing disease categories in trauma, cancer, congenital anomalies, maternal/reproductive health, aging, and infection were identified for inclusion to assess surgical capacity. CONCLUSIONS: This surgical basket facilitates a more standardized assessment of a country's surgical system. Further testing and refinement will likely be needed, but this basket can be used immediately to guide ongoing monitoring and evaluation of global surgery capacities to improve and strengthen surgery and anesthesia care.

Laparoscopy-assisted Transanal Endorectal Pull-through for the Management of Hirschsprung's Disease in Nigeria: Report of Two Cases.

Hirschsprung's disease is a relatively common disease in pediatric colorectal surgery. The treatment modalities have evolved from third-stage to single-stage in the past three decades. The single-stage procedure can be performed using the open, transanal or laparoscopy-assisted techniques. We use these cases to illustrate the first laparoscopically assisted procedures for Hirschsprung's disease in our center. The laparoscopic-assisted technique is described, and lessons in collaboration across institutions and within institutions are discussed.

Determination of Visual Portfolio for Surgeons OverSeas Assessment of Surgical Needs Nigeria Study: Consensus Generation through an e-Delphi Process.

BACKGROUND: Surgery as a public health priority has received little attention until recently. There is a significant unmeasured and unmet burden of surgical illness in low- and middle-income countries (LMICs). Our aim was to generate a consensus among expert pediatric surgeons practicing in LMICs regarding the spectrum of pediatric surgical conditions that we should look out for in a community-based survey for Surgeons OverSeas Assessment of Surgical Needs Nigeria study. MATERIALS AND METHODS: The Delphi methodology was utilized to identify sets of variables from among a panel of experts. Each variable was scored on a 5-point Likert scale. The experts were provided with an anonymous summary of the results after the first round. A consensus was achieved after two rounds, defined by an improvement in the standard deviation (SD) of scores for a particular variable over that of the previous round. We invited 76 pediatric surgeons through e-mail across Africa but predominantly from Nigeria. RESULTS: Twenty-one pediatric surgeons gave consent to participate through return of mail. Thirteen (62%) answered the first round statements and 8 (38%) the second round. In general, the strength of agreement to all statements of the questionnaire improved between the first and second rounds. Overall consensus, as expressed by the decrease in the mean SD from 0.84 in the first round to 0.68 in the second round, also improved over time. The strength of consensus improved for 23 (74%) of the statements. The strength of consensus decreased for the remaining 8 (26%) of statements. Out of the 31 consensus-generating statements, 16 (51%) scored high agreement, 13 (42%) scored low agreement, and 2 (15%) scored perfect disagreement. CONCLUSION: We have successfully identified the pediatric surgical conditions to be included in any community survey of pediatric surgical need in an LMIC setting.

Is Global Pediatric Surgery a Good Investment?

Investing in surgery has been highlighted as integral to strengthening overall health systems and increasing economic prosperity in low-income and middle-income countries (LMICs). The provision of surgical care in LMICs not only affects economies on a macro-level, but also impacts individual families within communities at a microeconomic level. Given that children represent 50% of the population in LMICs and the burden of unmet surgical needs in these areas is high, investing pediatric-specific components of surgical and anesthesia care is needed. Implementation efforts for pediatric surgical care include incorporating surgery-specific priorities into the global child health initiatives, improving global health financing for scale-up activities for children, increasing financial risk protection mechanisms for families of children with surgical needs, and including comprehensive pediatric surgical models of care into country-level plans.

Is the plastibell of any haemostatic value after 24 h?

BACKGROUND: The Plastibell is the most popular circumcision method among mothers in our city. Haemorrhage is its major problem. At our centre, we have recorded many circumcision problems resulting from prolonged retention of the Plastibell ring and this study, therefore, sought to explore the ways of reducing complications resulting from prolonged retention of the ring. PATIENTS AND METHODS: This was a prospective study, in which a total of sixty consecutive male neonates were recruited with all undergoing circumcision using the Plastibell device. Thirty patients were assigned to the subject group, in whom the Plastibell ring was removed by the investigator at 24 h while the other thirty constituted the control group whose Plastibell rings were allowed to fall off on their own. The patients selected were aged between 7 and 28 days. RESULTS: Overall, 4 (6.6%) of the sixty neonatal circumcisions in this study were complicated by haemorrhage. There was minor bleeding in 3 (10%) of the thirty subjects and 1 (3.3%) of the thirty controls. There was no statistically significant difference between the groups (P = 0.3006). One patient each from the subject and control groups bled following slipped ligature a few hours after Plastibell circumcision. The other two patients in the subject group bled following the removal of the Plastibell ring at 24 h. All the bleeding episodes were effectively controlled within 5 min by firm digital pressure only administered through a piece of dry, sterile gauze. CONCLUSION: Post-circumcision haemorrhage was not significantly different between circumcised babies whose Plastibell rings were removed at 24 h and those in whom it was left to fall off on its own.

Factors influencing waiting time in hypospadias repair surgery.

AIMS: Hypospadias is a common congenital anomaly of the urethra and phallus, which is not life threatening. It is thus less prioritised in a resource-limited setting. The aim of this study was to evaluate the management of hypospadias by our paediatric surgery unit and determine the factors affecting the delay between presentation and surgical repair while proffering possible solutions to such delay in hypospadias repair surgery. PATIENTS AND METHODS: This was a retrospective review of all hypospadias repair surgeries carried out by our paediatric surgery unit over a 38-month period, evaluating the period between presentation and first surgery for each patient. Data were analysed using IBM SPSS Statistics for Windows, Version 20.0 (IBM Corp., Released 2011, Armonk, NY, USA). Chi-square test was used to compare categorical variables and P ≤ 0.05 was considered significant. RESULTS: In 38 months, 47 operations for hypospadias were carried out on 42 boys. Thirty-seven patients (88.1%) had >3 months delay to surgery. The most frequent contributory factor to delay was unavailable theatre space (13 patients, 31%). Surgical outcome was good in only 16 patients (44%). Of the 16 patients with good outcome, 10 (63%) were operated between the ages of 2-4 years (P > 0.05). CONCLUSIONS: Multiple factors are responsible for delays in carrying out hypospadias surgery in resource-limited environments, notably securing a functional operating theatre suite in the light of more urgent conditions. To combat these delays, we recommend having dedicated hypospadias repair sessions and surgeons dedicated to hypospadias repair. Hypospadias outreach camps are also proposed.

Neonatal neuroblastoma with adrenal primary and metastasis to the liver: A case report and a review of literature.

We report the case of a 23-day-old neonate with neuroblastoma (NBL) in the right adrenal gland and widespread metastases to the liver. This raises the possibility of foetal NBL, which was missed during periodic ultrasonography done during the mother's pregnancy. We hope that this report would increase the awareness of physicians about foetal, congenital and neonatal NBL; and of sonographers about space-occupying lesions in the foetus. The clinicopathologic features and the management of neonatal NBL are discussed.

Diagnostic value of high resolution ultrasound in localisation of the undescended testis in children.

BACKGROUND: The use of ultrasonography in the pre-operative localisation of undescended testes has become controversial due to fears about its accuracy. This study was designed to ascertain the accuracy, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of ultrasonography in the localisation of the undescended testes in children. PATIENTS AND METHODS: A prospective evaluation of all boys undergoing operation for undescended testes at the Lagos University Teaching Hospital, Idi-Araba, Lagos, over a 12 month period was performed. The pre-operative clinical and ultrasound findings were compared with the findings on surgical exploration. RESULTS: Forty boys with 52 undescended testes were studied. The mean age of the boys at the time of surgery was 4.0 ± 0 years (range 1-11 years). Forty-six (88.5%) testes were localised pre-operatively by ultrasound- 20 of 22 (90.9%) palpable testes and 26 of 30 (86.7%) non-palpable testes. Intra-operatively, 49 (94.2%) of the undescended testes were found while 3 (5.8%) were absent/vanishing testes. Ultrasound evaluation had an accuracy of 86.5%, sensitivity of 89.8%, and specificity of 33.3%, PPV of 95.7% and a NPV of 16.7%. CONCLUSION: Ultrasound assessment is beneficial in pre-operative evaluation of children with undescended testes.

Routine haemoglobin electrophoresis screening in day case herniotomy in Nigerian children: Is it evidence-based?

BACKGROUND: To determine the prevalence of haemoglobinopathies in children who require day case herniotomy in our centre and ascertain if routine screening is necessary in all patients who require herniotomy. MATERIALS AND METHODS: A 12-month retrospective analysis of patients requiring herniotomy in our centre. Data including age, sex, diagnosis, haemoglobin electrophoresis status, surgical outcome and hospital stay were analysed. RESULTS: Ninety-five patients had complete records. There were 84 boys and 11 girls. M:F ratio: 7.6:1. The mean age was 3.2 ± 0.6 years. Fifty-five point eight per cent of the patients had right inguinal hernias while 35.8% had left inguinal hernias. Eight patients (8.4%) had bilateral inguinal hernias. Twenty-six patients (27.4%) had haemoglobinopathies while 69 patients (72.6%) had homozygous Haemoglobin A. The Sickle Cell trait (HbAS) was found in 22 patients (23.2%) while the HbAC was found in three patients (3.2%). One patient (1.1%) had Sickle Cell disease (Haemoglobin SS). He had had blood transfusion and previous history of jaundice. All patients survived and all patients were discharged on the day of surgery (mean hospital stay: 4hrs (range: 2.5 hrs-12 hrs)) except the patient with Sickle Cell disease who was admitted a day before surgery and discharged a day after the operation. CONCLUSION: One in four children coming for day case herniotomy in our centre had the Sickle Cell trait while only 1% had the Sickle Cell disease. These findings are in keeping with the prevalence in the Nigerian population. Routine screening may not be necessary for all patients coming for herniotomy in our centre. Clear indication(s) should be outlined for screening.