GAPS phase II: development and pilot results of the global assessment in pediatric surgery, an evidence-based pediatric surgical capacity assessment tool for low-resource settings.

PURPOSE: Pediatric surgical care in low- and middle-income countries is often hindered by systemic gaps in healthcare resources, infrastructure, training, and organization. This study aims to develop and validate the Global Assessment of Pediatric Surgery (GAPS) to appraise pediatric surgical capacity and discriminate between levels of care across diverse healthcare settings. METHODS: The GAPS Version 1 was constructed through a synthesis of existing assessment tools and expert panel consultation. The resultant GAPS Version 2 underwent international pilot testing. Construct validation categorized institutions into providing basic or advanced surgical care. GAPS was further refined to Version 3 to include only questions with a > 75% response rate and those that significantly discriminated between basic or advanced surgical settings. RESULTS: GAPS Version 1 included 139 items, which, after expert panel feedback, was expanded to 168 items in Version 2. Pilot testing, in 65 institutions, yielded a high response rate. Of the 168 questions in GAPS Version 2, 64 significantly discriminated between basic and advanced surgical care. The refined GAPS Version 3 tool comprises 64 questions on: human resources (9), material resources (39), outcomes (3), accessibility (3), and education (10). CONCLUSION: The GAPS Version 3 tool presents a validated instrument for evaluating pediatric surgical capabilities in low-resource settings.

Unifying Children's Surgery and Anesthesia Stakeholders Across Institutions and Clinical Disciplines: Challenges and Solutions from Uganda.

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.

Pediatric Surgery Collaboration in Uganda, the Benefits of Long Term Partnerships at Regional Referral Hospitals.

Background: In 2022 there were only seven pediatric surgeons in Uganda, but approximately 170 are needed. Consequently, Ugandan general surgeons treat most pediatric surgical problems at regional hospitals. Accordingly, stakeholders created the Pediatric Emergency Surgery Course, which teaches rural providers identification, resuscitation, treatment and referral of pediatric surgical conditions. In order to improve course offerings and better understand pediatric surgery needs we collected admission and operative logbook data from four participating sites. One participating site, Lacor Hospital, rarely referred patients and had a much higher operative volume. Therefore, we sought to understand the causes of this difference and the resulting economic impact. Methods: Over a four-year period, data was collected from logbooks at four different regional referral hospitals in Uganda. Patients ≤ 18 years old with a surgical diagnosis were included. Patient LOS, referral volume, age, and case type were compared between sites and DALYs were calculated and converted into monetary benefit. Results: Over four sites, 8,615 admissions, and 5,457 cases were included. Lacor patients were younger, had a longer length of stay, and were referred less. Additionally, Lacor's long-term partnerships with a high-income country institution, a missionary organization, and visiting Ugandan and international pediatric surgeons were unique. In 2018, the pediatric surgery case volume was: Lacor (967); Fort Portal (477); Kiwoko (393); and Kabale (153), resulting in a substantial difference in long-term monetary health benefit. Conclusion: Long-term international partnerships may advance investments in surgical infrastructure, workforce, and education in low- and middle-income countries. This collaborative model allows stakeholders to make a greater impact than any single institution could make alone.

Access to pediatric surgery delivered by general surgeons and anesthesia providers in Uganda: Results from 2 rural regional hospitals.

BACKGROUND: Significant limitations in pediatric surgical capacity exist in low- and middle-income countries, especially in rural regions. Recent global children's surgical guidelines suggest training and support of general surgeons in rural regional hospitals as an effective approach to increasing pediatric surgical capacity. METHODS: Two years of a prospective clinical database of children's surgery admissions at 2 regional referral hospitals in Uganda were reviewed. Primary outcomes included case volume and clinical outcomes of children at each hospital. Additionally, the disability-adjusted life-years averted by delivery of pediatric surgical services at these hospitals were calculated. Using a value of statistical life calculation, we also estimated the economic benefit of the pediatric surgical care currently being delivered. RESULTS: From 2016 to 2019, more than 300 surgical procedures were performed at each hospital per year. The majority of cases were standard general surgery cases including hernia repairs and intussusception as well as procedures for surgical infections and trauma. In-hospital mortality was 2.4% in Soroti and 1% in Lacor. Pediatric surgical capacity at these hospitals resulted in over 12,400 disability-adjusted life-years averted/year. This represents an estimated economic benefit of 10.2 million US dollars/year to the Ugandan society. CONCLUSION: This investigation demonstrates that lifesaving pediatric procedures are safely performed by general surgeons in Uganda. General surgeons who perform pediatric surgery significantly increase surgical access to rural regions of the country and add a large economic benefit to Ugandan society. Overall, the results of the study support increasing pediatric surgical capacity in rural areas of low- and middle-income countries through support and training of general surgeons and anesthesia providers.

Cervical thymic cysts.

Thymic cysts are rare embryonic remnants along the course of thymic migration in the neck or the anterior mediastinum which may result in cervical masses in children, often misdiagnosed. We present the experience gained by three European tertiary care medical centers in the treatment of thymic cysts as well as the current data on the embryology, clinical presentation, diagnosis and management of thymic cysts. A retrospective study was carried out in nine patients with thymic cysts during the period 1986-2002 at the departments of Pediatric Surgery of Children's University Hospital "Federico II" and "Santobono" Pediatric Hospital of Naples in Italy and "Aghia Sophia" Children's Hospital of Athens in Greece. All cases were asymptomatic, appearing mainly as masses resembling branchial cyst or lymphatic malformation. Laboratory and imaging investigations were not useful for preoperative diagnosis. In one case the mass extended into the mediastinum. The histological findings of thymic tissue and Hassal's corpuscles in the cystic wall were diagnostic. In all cases, surgery was successful and uneventful. Surgical excision was accomplished by dissection of the cystic masses from the jugular vein, carotid artery and vagus nerve and from the sternocleidomastoid muscle. The presence of a normal thymus in the mediastinum must be documented preoperatively in order to avoid the risk of total thymectomy. If a cervical thymic cyst extends into the normal thymus, attempts should be made to preserve the thymus, especially in younger patients. Thymic cysts should always be included in the differential diagnosis of lateral cervical masses, especially in children.

Laparoscopic antireflux procedures in the management of gastroesophageal reflux following esophageal atresia repair.

OBJECTIVES: The validity of open fundoplication after esophageal atresia (EA) repair is still disputed. The authors have retrospectively evaluated the results achieved in their centers using laparoscopic antireflux procedures (LARP) in children operated for EA at birth. METHODS: From 1998 to 2002, 350 children underwent LARP. Of these, 21 (6%) underwent EA repair at birth. Our study focused only on the management of these 21 patients; 5 of them (23.8%) were neurologically impaired children (NIC). All underwent LARP, 9 patients according to Nissen, 9 according to Thal, and 3 according to Toupet. The 5 NIC with feeding problems underwent concomitant g-tube placement during the same procedure. RESULTS: All the procedures were completed in laparoscopy, without intraoperative complications. The mean operative time was 65 minutes (range 45-140). We had no mortality in our series. Hospital stay varied from 2 to 9 days (median 3 days). At a maximum follow-up of 6 years, all patients were evaluated with a 24-hours pH-metry and barium swallow. The 16 neurologically normal children were free of symptoms at the last follow-up; five of them (31.2%) had mild dysphagia, which disappeared spontaneously within 3-6 months. One girl experienced an important episode of aspiration 2 years after the LARP, although there was no evidence of reflux at the follow-up examinations. As for the 5 NIC, one patient eats only through a g-tube, the other 4 undergo mixed feeding (g-tube and mouth); none have signs of GER, but two of them still present respiratory symptoms, and one has delayed gastric emptying. CONCLUSIONS: In our experience laparoscopic antireflux surgery is an appropriate treatment of GER in children operated for EA at birth, independently of the antireflux mechanism adopted; the 31.2% rate of short-term dysphagia presenting as residual respiratory symptoms may be due to a primary dysmotility of the esophagus consequent to the esophageal atresia.

Pilomatricoma in childhood: a retrospective study from three European paediatric centres.

UNLABELLED: Pilomatricoma is characterised as a common, slowly growing benign cutaneous tumour that appears generally within the first decades of life. The clinical diagnosis is frequently missed, especially by the paediatrician unfamiliar with these tumours. We present the experience gained in three European tertiary care paediatric centres with the treatment of pilomatricoma and also current data on the aetiology, clinical presentation and management. A retrospective study was carried out in 83 patients suspected for pilomatricoma during a 7-year period (1996-2002) at the departments of Paediatric Surgery of the Children's University Hospital "Federico II", Naples, Hospital "San Bortolo", Vicenza and "Aghia Sophia" Children's Hospital, Athens. The age range was from 10 months to 17 years, median age 8 years. All patients were treated by surgical excision and all specimens were examined by histopathological assessment. The follow-up varied from 5 months to 6 years. The correct diagnosis was made preoperatively in 68 patients (82%). The female/male ratio was 2:1. The sites of occurrence were the head (47.5%), especially in the periorbital region, the neck (9%), the upper limbs (35.5%), the inferior limbs (4%) and the thorax (4%). Each patient exhibited a single pilomatricoma except for two patients who had multiple lesions (2.4%). One of them had Steinert disease (myotonic dystrophy). No recurrences were observed during the follow-up period. CONCLUSION: Pilomatricoma is one of the most common cutaneous adnexal neoplasms in children. Surgical excision including clear margins and its overlying skin in most cases is the treatment of choice. The recurrence as well as malignant evolution is rare.