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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.
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Países en Desarrollo , Recursos en Salud , Pediatría , Humanos , Proyectos Piloto , Pediatría/educación , Salud Global , Niño , Procedimientos Quirúrgicos Operativos , Especialidades Quirúrgicas/educaciónRESUMEN
Background: Grading scales for adverse surgical outcomes have been poorly characterized to date. The primary aim of this study was to conduct a systematic review to enumerate the various frameworks for grading adverse postoperative outcomes; our secondary objective was to outline the properties of each grading system, identifying its strengths and weaknesses. Methods: We searched 9 databases (Africa Wide Information, Biosis, Cochrane, Embase, Global Health, LILACs, Medline, PubMed and Web of Science) from 1992 (the year the Clavien-Dindo classification system was developed) until Mar. 2, 2017, for studies that aimed to develop or improve on an already existing generalizable system for grading adverse postoperative outcomes. Study selection was duplicated as per PRISMA recommendations. Procedure-specific grading systems were excluded. We assessed the framework, strengths and weaknesses of the systems qualitatively. Results: We identified 9 studies on 8 adverse outcome grading systems with frameworks generalizable to any surgical procedure. Most systems have not been widely incorporated in the literature. Seven of the 8 systems were produced without including patients' perspectives. Four allowed the derivation of a composite morbidity score, which had limited tangible significance for patients. Conclusion: Although each instrument identified offered its own advantages, none satisfied the need for a patient-centred tool capable of generating a composite score of all possible postoperative adverse outcomes (complications, sequelae and failure) that enables comparison of noninterventional and surgical management of disease. There is a need for development of a more comprehensive, patient-centred grading system for adverse postoperative outcomes.
Contexte: Jusqu'ici, les systèmes de classification des issues postopératoires indésirables n'ont pas encore fait l'objet d'une analyse comparative. Cette étude avait pour objectif principal de recenser, au moyen d'une revue systématique de la littérature, les divers systèmes de classification des issues postopératoire indésirables, et pour objectif secondaire de dégager les propriétés, les forces et les faiblesses de chaque système. Méthodes: Nous avons interrogé 9 bases de données (Africa Wide Information, Biosis Previews, Cochrane, Embase, Global Health, LILACS, Medline, PubMed et Web of Science) pour trouver des articles publiés entre 1992 (année de la mise au point du système de classification de ClavienDindo) et le 2 mars 2017. Ces articles devaient porter sur la création d'un système généralisable de classification des issues postopératoires indésirables, ou l'amélioration d'un système existant. La sélection des études a été faite en double, conformément aux recommandations PRISMA. Les systèmes de classification visant une seule intervention ont été exclus. Nous avons évalué, d'un point de vue qualitatif, le cadre, les forces et les faiblesses des systèmes retenus. Résultats: Nous avons retenu 9 études sur 8 systèmes de classification accompagnés d'un cadre pouvant être appliqué à n'importe quelle intervention chirurgicale. La plupart des systèmes n'avaient pas été largement étudiés. Sept des 8 systèmes avaient été développés sans tenir compte du point de vue des patients, et 4 permettaient de calculer un score de morbidité composite ayant des retombées concrètes limitées pour les patients. Conclusion: Tous les systèmes retenus s'accompagnaient d'avantages, mais aucun ne pouvait servir d'outil centré sur le patient permettant de calculer un score composite pour toutes les issues postopératoires possibles (complications, séquelles et échec), score qui pourrait servir à comparer les prises en charge conservatrice et chirurgicale des maladies. La création d'un système de classification des issues postopératoires indésirables exhaustif centré sur le patient est nécessaire.
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Complicaciones Posoperatorias/clasificación , Índice de Severidad de la Enfermedad , HumanosRESUMEN
OBJECTIVES: Cases of esophageal carcinoma have been documented in survivors of esophageal atresia (EA). Children with EA undergo considerable amounts of diagnostic imaging and consequent radiation exposure potentially increasing their lifetime cancer mortality risk. This study evaluates the radiological procedures performed on patients with EA and estimates their cumulative radiation exposure and attributable lifetime cancer mortality risk. METHODS: Medical records of patients with EA managed at a tertiary care center were reviewed for demographics, EA subtype, and number and type of radiological investigations. Existing normative data were used to estimate the cumulative radiation exposure and lifetime cancer risk per patient. RESULTS: The present study included 53 patients with a mean follow-up of 5.7 years. The overall median and maximum estimated effective radiation dose in the neonatal period was 5521.4 µSv/patient and 66638.6 µSv/patient, respectively. This correlates to a median and maximum estimated cumulative lifetime cancer mortality risk of 1:1530 and 1:130, respectively. Hence, radiation exposure in the neonatal period increased the cumulative cancer mortality risk a median of 130-fold and a maximum of 1575-fold in EA survivors. CONCLUSIONS: Children with EA are exposed to significant amounts of radiation and an increased estimated cumulative cancer mortality risk. Efforts should be made to eliminate superfluous imaging.
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Atresia Esofágica/diagnóstico por imagen , Neoplasias Esofágicas/etiología , Exposición a la Radiación/efectos adversos , Atresia Esofágica/complicaciones , Neoplasias Esofágicas/epidemiología , Neoplasias Esofágicas/mortalidad , Femenino , Humanos , Recién Nacido , Masculino , Dosis de Radiación , Estudios Retrospectivos , Medición de Riesgo/métodos , Factores de RiesgoRESUMEN
BACKGROUND: Surgical care is critical to establish effective healthcare systems in low- and middle-income countries, yet the unmet need for surgical conditions is as high as 65% in Ugandan children. Financial burden and geographical distance are common barriers to help-seeking in adult populations and are unmeasured in the pediatric population. We thus measured out-of-pocket (OOP) expenses and distance traveled for pediatric surgical care in a tertiary hospital in Mbarara, Uganda, as compared to adult surgical and pediatric medical patients. METHODS: Patients admitted to pediatric surgical (n = 20), pediatric medical (n = 18) and adult surgical (n = 18) wards were interviewed upon discharge over a period of 3 weeks. Patient and caregiver-reported expenses incurred for the present illness included prior/future care needed, and travel distance/cost. The prevalence of catastrophic expenses (≥10% of annual income) was calculated and spending patterns compared between wards. RESULTS: Thirty-five percent of pediatric medical patients, 45% of pediatric surgical patients and 55% of adult surgical patients incurred catastrophic expenses. Pediatric surgical patients paid more for their current treatment (p < 0.01)-specifically medications (p < 0.01) and tests (p < 0.01)-than pediatric medical patients, and comparable costs to adults. Adult patients paid more for treatment prior to the hospital (p = 0.04) and miscellaneous expenses (e.g., food while admitted) (p = 0.02). Patients in all wards traveled comparable distances. CONCLUSIONS: Seeking healthcare at a publicly funded hospital is financially catastrophic for almost half of patients. Out-of-stock supplies and broken equipment make surgical care particularly vulnerable to OOP expenses because analgesics, anaesthesia and preoperative imaging are prerequisites to care.
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Enfermedad Catastrófica/economía , Gastos en Salud , Procedimientos Quirúrgicos Operativos/economía , Adulto , Niño , Costo de Enfermedad , Femenino , Hospitales Públicos , Humanos , Masculino , Centros de Atención Terciaria , UgandaRESUMEN
BACKGROUND: No consensus exists for the initial management of infants with gastroschisis. METHODS: The American Pediatric Surgical Association (APSA) Outcomes and Evidenced-based Practice Committee (OEBPC) developed three a priori questions about gastroschisis for a qualitative systematic review. We reviewed English-language publications between January 1, 1970, and December 31, 2019. This project describes the findings of a systematic review of the three questions regarding: 1) optimal delivery timing, 2) antibiotic use, and 3) closure considerations. RESULTS: 1339 articles were screened for eligibility; 92 manuscripts were selected and reviewed. The included studies had a Level of Evidence that ranged from 2 to 4 and recommendation Grades B-D. Twenty-eight addressed optimal timing of delivery, 5 pertained to antibiotic use, and 59 discussed closure considerations (Figure 1). Delivery after 37 weeks post-conceptual age is considered optimal. Prophylactic antibiotics covering skin flora are adequate to reduce infection risk until definitive closure. Studies support primary fascial repair, without staged silo reduction, when abdominal domain and hemodynamics permit. A sutureless repair is safe, effective, and does not delay feeding or extend length of stay. Sedation and intubation are not routinely required for a sutureless closure. CONCLUSIONS: Despite the large number of studies addressing the above-mentioned facets of gastroschisis management, the data quality is poor. A wide variation in gastroschisis management was documented, indicating a need for high quality RCTs to provide an evidence-based approach when caring for these infants. TYPE OF STUDY: Qualitative systematic review of Level 1-4 studies.
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Antibacterianos , Gastrosquisis , Humanos , Gastrosquisis/cirugía , Antibacterianos/administración & dosificación , Antibacterianos/uso terapéutico , Recién Nacido , Profilaxis Antibiótica/métodos , Infección de la Herida Quirúrgica/prevención & control , Infección de la Herida Quirúrgica/epidemiología , Parto Obstétrico/métodos , Factores de TiempoRESUMEN
OBJECTIVE: The American Pediatric Surgical Association Outcomes and Evidence-Based Practice Committee conducted a systematic review to describe the epidemiology of venous thromboembolism (VTE) in pediatric surgical and trauma patients and develop recommendations for screening and prophylaxis. METHODS: The Medline (Ovid), Embase, Cochrane, and Web of Science databases were queried from January 2000 through December 2021. Search terms addressed the following topics: incidence, ultrasound screening, and mechanical and pharmacologic prophylaxis. The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines were followed. Consensus recommendations were derived based on the best available literature. RESULTS: One hundred twenty-four studies were included. The incidence of VTE in pediatric surgical populations is 0.29% (Range = 0.1%-0.48%) and directly correlates with surgery type, transfusion, prolonged anesthesia, malignancy, congenital heart disease, inflammatory bowel disease, infection, and female sex. The incidence of VTE in pediatric trauma populations is 0.25% (Range = 0.1%-0.8%) and directly correlates with injury severity, major surgery, central line placement, body mass index, spinal cord injury, and length-of-stay. Routine ultrasound screening for VTE is not recommended. Consider sequential compression devices in at-risk nonmobile, pediatric surgical patients when an appropriate sized device is available. Consider mechanical prophylaxis alone or with pharmacologic prophylaxis in adolescents >15 y and post-pubertal children <15 y with injury severity scores >25. When utilizing pharmacologic prophylaxis, low molecular weight heparin is superior to unfractionated heparin. CONCLUSIONS: While VTE remains an infrequent complication in children, consideration of mechanical and pharmacologic prophylaxis is appropriate in certain populations. TYPE OF STUDY: Systematic Review of level 2-4 studies. LEVEL OF EVIDENCE: Level 3-4.
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BACKGROUND: Significant variation in management strategies for lymphatic malformations (LMs) in children persists. The goal of this systematic review is to summarize outcomes for medical therapy, sclerotherapy, and surgery, and to provide evidence-based recommendations regarding the treatment. METHODS: Three questions regarding LM management were generated according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Publicly available databases were queried to identify articles published from January 1, 1990, to December 31, 2021. A consensus statement of recommendations was generated in response to each question. RESULTS: The initial search identified 9326 abstracts, each reviewed by two authors. A total of 600 abstracts met selection criteria for full manuscript review with 202 subsequently utilized for extraction of data. Medical therapy, such as sirolimus, can be used as an adjunct with percutaneous treatments or surgery, or for extensive LM. Sclerotherapy can achieve partial or complete response in over 90% of patients and is most effective for macrocystic lesions. Depending on the size, extent, and location of the malformation, surgery can be considered. CONCLUSION: Evidence supporting best practices for the safety and effectiveness of management for LMs is currently of moderate quality. Many patients benefit from multi-modal treatment determined by the extent and type of LM. A multidisciplinary approach is recommended to determine the optimal individualized treatment for each patient.
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OBJECTIVE: Treatment of neonates with anorectal malformations (ARMs) can be challenging due to variability in anatomic definitions, multiple approaches to surgical management, and heterogeneity of reported outcomes. The purpose of this systematic review is to summarize existing evidence, identify treatment controversies, and provide guidelines for perioperative care. METHODS: The American Pediatric Surgical Association Outcomes and Evidence Based Practice Committee (OEBP) drafted five consensus-based questions regarding management of children with ARMs. These questions were related to categorization of ARMs and optimal methods and timing of surgical management. A comprehensive search strategy was performed, and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used to perform the systematic review to attempt to answer five questions related to surgical care of ARM. RESULTS: A total of 10,843 publications were reviewed, of which 90 were included in final recommendations, and some publications addressed more than one question (question: 1 n = 6, 2 n = 63, n = 15, 4 n = 44). Studies contained largely heterogenous groups of ARMs, making direct comparison for each subtype challenging and therefore, no specific recommendation for optimal surgical approach based on outcomes can be made. Both loop and divided colostomy may be acceptable methods of fecal diversion for patients with a diagnosis of anorectal malformation, however, loop colostomies have higher rates of prolapse in the literature reviewed. In terms of timing of repair, there did not appear to be significant differences in outcomes between early and late repair groups. Clear and uniform definitions are needed in order to ensure similar populations of patients are compared moving forward. Recommendations are provided based primarily on A-D levels of evidence. CONCLUSIONS: Evidence-based best practices for ARMs are lacking for many aspects of care. Multi-institutional registries have made progress to address some of these gaps. Further prospective and comparative studies are needed to improve care and provide consensus guidelines for this complex patient population.
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INTRODUCTION: The incidence of ulcerative colitis (UC) is increasing. Roughly 20% of all patients with UC are diagnosed in childhood, and children typically present with more severe disease. Approximately 40% will undergo total colectomy within ten years of diagnosis. The objective of this study is to assess the available evidence regarding the surgical management of pediatric UC as determined by the consensus agreement of the American Pediatric Surgical Association Outcomes and Evidence-Based Practice Committee (APSA OEBP). METHODS: Through an iterative process, the membership of the APSA OEBP developed five a priori questions focused on surgical decision-making for children with UC. Questions focused on surgical timing, reconstruction, use of minimally invasive techniques, need for diversion, and risks to fertility and sexual function. A systematic review was conducted, and articles were selected for review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Risk of Bias was assessed using Methodological Index for Non-Randomized Studies (MINORS) criteria. The Oxford Levels of Evidence and Grades of Recommendation were utilized. RESULTS: A total of 69 studies were included for analysis. Most manuscripts contain level 3 or 4 evidence from single-center retrospective reports, leading to a grade D recommendation. MINORS assessment revealed a high risk of bias in most studies. J-pouch reconstruction may result in fewer daily stools than straight ileoanal anastomosis. There are no differences in complications based on the type of reconstruction. The timing of surgery should be individualized to patients and does not affect complications. Immunosuppressants do not appear to increase surgical site infection rates. Laparoscopic approaches result in longer operative times but shorter lengths of stay and fewer small bowel obstructions. Overall, complications are not different using an open or minimally invasive approach. CONCLUSIONS: There is currently low-level evidence related to certain aspects of surgical management for UC, including timing, reconstruction type, use of minimally invasive techniques, need for diversion, and risks to fertility and sexual function. Multicenter, prospective studies are recommended to better answer these questions and ensure the best evidence-based care for our patients. LEVEL OF EVIDENCE: Level of evidence III. STUDY TYPE: Systematic review.
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Colitis Ulcerosa , Humanos , Niño , Adolescente , Colitis Ulcerosa/cirugía , Estudios Retrospectivos , Estudios Prospectivos , Colectomía/métodos , Infección de la Herida Quirúrgica , Estudios Multicéntricos como AsuntoRESUMEN
INTRODUCTION: Controversy exists in the optimal management of adolescent and young adult primary spontaneous pneumothorax. The American Pediatric Surgical Association (APSA) Outcomes and Evidence-Based Practice Committee performed a systematic review of the literature to develop evidence-based recommendations. METHODS: Ovid MEDLINE, Elsevier Embase, EBSCOhost CINAHL, Elsevier Scopus, and Wiley Cochrane Central Register of Controlled Trials databases were queried for literature related to spontaneous pneumothorax between January 1, 1990, and December 31, 2020, addressing (1) initial management, (2) advanced imaging, (3) timing of surgery, (4) operative technique, (5) management of contralateral side, and (6) management of recurrence. The Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines were followed. RESULTS: Seventy-nine manuscripts were included. Initial management of adolescent and young adult primary spontaneous pneumothorax should be guided by symptoms and can include observation, aspiration, or tube thoracostomy. There is no evidence of benefit for cross-sectional imaging. Patients with ongoing air leak may benefit from early operative intervention within 24-48 h. A video-assisted thoracoscopic surgery (VATS) approach with stapled blebectomy and pleural procedure should be considered. There is no evidence to support prophylactic management of the contralateral side. Recurrence after VATS can be treated with repeat VATS with intensification of pleural treatment. CONCLUSIONS: The management of adolescent and young adult primary spontaneous pneumothorax is varied. Best practices exist to optimize some aspects of care. Further prospective studies are needed to better determine optimal timing of operative intervention, the most effective operation, and management of recurrence after observation, tube thoracostomy, or operative intervention. LEVEL OF EVIDENCE: Level 4. TYPE OF STUDY: Systematic Review of Level 1-4 studies.
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Neumotórax , Niño , Humanos , Adolescente , Adulto Joven , Neumotórax/diagnóstico , Neumotórax/etiología , Neumotórax/cirugía , Tubos Torácicos , Cirugía Torácica Asistida por Video/métodos , Toracotomía , Práctica Clínica Basada en la Evidencia , Estudios Retrospectivos , Recurrencia , Resultado del TratamientoRESUMEN
BACKGROUND: Hepatitis B virus (HBV) infections are responsible for the development of chronic hepatitis in 400 million people worldwide. Currently, no consensus exists as to when treatment should be initiated for pediatric patients. OBJECTIVES: To evaluate the risks and predictive factors of success of lamivudine treatment in children with chronic, active HBV infection. METHODS: Forty-three children (22 male, median age 9.6 years) chronically infected with HBV and treated between 1998 and 2008 at CHU Ste-Justine (Montreal, Quebec) were included in the present chart review study. Inclusion criteria were detectable hepatitis B surface antigen and hepatitis B e antigen (HBeAg), minimum serum alanine aminotransferase (ALT) level of two times the upper limit of normal and detectable serum HBV DNA for at least three months. Patients received lamivudine for a minimum of six months (median 14 months). Genotyping was performed. RESULTS: Lamivudine treatment was effective in 35% of cases (15 of 43) and overall virological response (during or after treatment) was achieved in 51% of patients. Three patients harboured suspected lamivudine-resistant mutations and five progressed to HBeAg-chronic HBV. Predictive factors for success of treatment were: younger age at beginning of treatment (P=0.05), elevated ALT levels throughout treatment duration (P=0.003) and loss of HBeAg during treatment (P=0.016). Asian origin did not affect treatment success or spontaneous viral control during follow-up. HBV genotype did not influence treatment success. CONCLUSIONS: Lamivudine treatment in a carefully selected cohort of HBV patients demonstrated a good rate of success and low incidence of mutation. Younger age at the beginning of treatment and high ALT levels during treatment predicted a positive outcome.
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Antivirales/uso terapéutico , Hepatitis B/tratamiento farmacológico , Lamivudine/uso terapéutico , Adolescente , Alanina Transaminasa/sangre , Niño , Preescolar , Femenino , Humanos , Masculino , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
OBJECTIVES: This study describes the management of patients with bilobar colorectal liver metastases (CRLM). METHODS: A retrospective collection of data on all patients with CRLM who were considered for staged resection (n= 85) from January 2003 to January 2011 was performed. Patients who underwent one hepatic resection were considered to have had a failed staged resection (FSR), whereas those who underwent a second or third hepatic resection to produce a cure were considered to have had a successful staged resection (SSR). Survival was calculated from the date of diagnosis of liver metastases. Complete follow-up and dates of death were obtained from the Government of Quebec population database. RESULTS: Median survival was 46 months (range: 30-62 months) in the SSR group and 22 months (range: 19-29 months) in the FSR group. Rates of 5-year survival were 42% and 4% in the SSR and FSR groups, respectively. Fifteen of the 19 patients who remained alive at the last follow-up date belonged to the SSR group. CONCLUSIONS: In patients in whom staged resection for bilobar CRLM is feasible, surgery would appear to offer benefit.
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Neoplasias Colorrectales/patología , Hepatectomía/métodos , Neoplasias Hepáticas/secundario , Neoplasias Hepáticas/cirugía , Anciano , Distribución de Chi-Cuadrado , Neoplasias Colorrectales/mortalidad , Supervivencia sin Enfermedad , Femenino , Hepatectomía/efectos adversos , Hepatectomía/mortalidad , Humanos , Estimación de Kaplan-Meier , Neoplasias Hepáticas/diagnóstico por imagen , Neoplasias Hepáticas/mortalidad , Modelos Logísticos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Oportunidad Relativa , Quebec , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Tomografía Computarizada por Rayos X , Resultado del TratamientoRESUMEN
PURPOSE: Low- and middle-income countries (LMICs) have only 19% of the global surgical workforce yet see 80% of worldwide deaths from noncommunicable diseases. We aimed to interrogate the correlation between pediatric surgical workforce density (PSWD) and survival from pediatric surgical conditions worldwide. METHODS: A systematic review of online databases identified outcome studies for key pediatric surgical conditions (gastroschisis, esophageal atresia, intestinal atresia, and typhoid perforation) as well as PSWD data across low-income (LICs), middle-income (MICs), and high-income countries (HICs). PSWD was expressed as the number of PSs/million children under 15â¯years of age and we correlated this to surgical outcomes for our case series. RESULTS: PSWD ranged between zero (Burundi, The Gambia, and Mauritania) and 125.2 (Poland) across 86 countries. Outcomes for at least one condition were obtained in 61 countries: 50 outcomes in HICs, 52 in MICs and 8 in LICs. The mean survival in our case series was 42.3%, 69.4% and 91.6% for LICs, MICs, and HICs, respectively. A PSWD ≥4 PSs/million children under 15â¯years of age significantly correlated to odds of survival ≥80% (OR 16.8, pâ¯<â¯0.0001, 95% CI 5.66-49.88). Specifically in the studied LICs and MICs, increasing the PSWD to 4 would require training 1427 additional surgeons. CONCLUSION: Using a novel approach, we have established a benchmark for the scale-up of pediatric surgical workforce, which may support broader efforts to reduce childhood deaths from congenital disease. LEVELS OF EVIDENCE: 2c - Outcomes Research.
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Pediatría/organización & administración , Cirujanos/estadística & datos numéricos , Procedimientos Quirúrgicos Operativos , Recursos Humanos/estadística & datos numéricos , Adolescente , Niño , Preescolar , Anomalías del Sistema Digestivo/cirugía , Humanos , Lactante , Recién Nacido , Pobreza , Procedimientos Quirúrgicos Operativos/mortalidad , Procedimientos Quirúrgicos Operativos/estadística & datos numéricos , Resultado del TratamientoRESUMEN
BACKGROUND: The purpose of this study was to estimate the unmet burden of surgically correctable congenital anomalies in African low- and middle-income countries (LMICs). METHODS: We conducted a chart review of children operated for cryptorchidism, isolated cleft lip, hypospadias, bladder exstrophy and anorectal malformation at an Ethiopian referral hospital between January 2012 and July 2016 and a scoping review of the literature describing the management of congenital anomalies in African LMICs. Procedure numbers and age at surgery were collected to estimate mean surgical delays by country and extrapolate surgical backlog. The unmet surgical need was derived from incidence-based disease estimates, established disability weights, and actual surgical volumes. RESULTS: The chart review yielded 210 procedures in 207 patients from Ethiopia. The scoping review generated 42 data sets, extracted from 36 publications, encompassing: Benin, Egypt, Ghana, Ivory Coast, Kenya, Nigeria, Madagascar, Malawi, Togo, Uganda, Zambia, and Zimbabwe. The largest national surgical backlog was noted in Nigeria for cryptorchidism (209,260 cases) and cleft lip (4154 cases), and Ethiopia for hypospadias (20,188 cases), bladder exstrophy (575 cases) and anorectal malformation (1349 cases). CONCLUSION: These data support the need for upscaling pediatric surgical capacity in LMICs to address the significant surgical delay, surgical backlog, and unmet prevalent need. TYPE OF STUDY: Retrospective study and review article LEVEL OF EVIDENCE: III.
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Anomalías Congénitas/cirugía , Costo de Enfermedad , Accesibilidad a los Servicios de Salud/estadística & datos numéricos , Necesidades y Demandas de Servicios de Salud/estadística & datos numéricos , Procedimientos de Cirugía Plástica/estadística & datos numéricos , Adolescente , África/epidemiología , Niño , Preescolar , Anomalías Congénitas/epidemiología , Países en Desarrollo , Femenino , Recursos en Salud , Humanos , Lactante , Masculino , Pobreza , Estudios Retrospectivos , TogoRESUMEN
BACKGROUND: In the absence of robust data from low- and middle-income countries (LMICs), most disease burden estimates and related resource allocation choices are based on historic Northern demographics. We hypothesize that significant discrepancies exist between directly reported LMIC data and surrogate high-income country (HIC) disease burden estimates of correctible congenital anomalies. METHODS: Nine online databases were searched for studies reporting incidence and prevalence data on surgically correctible congenital anomalies in LMICs between 2006 and 2017. Two independent reviewers screened titles and abstracts, with a third adjudicating discrepancies. Selected studies were reviewed and analyzed. RESULTS: Of 10,128 identified articles, 98 were extracted for full-text review, and 41 were included, representing 21 LMICs and 18 conditions. Study types included community surveys (34%), prospective (22%) and retrospective (17%) multi-site data, registries (12%), single-site data (12%), and systematic reviews (5%). Data collection periods were 1 to 10â¯years. The pooled epidemiologic data varied systematically from existing HIC literature, with the incidence of disease being generally lower in LMICs. CONCLUSIONS: Marked discrepancies exist between reported epidemiological data in LMICs and HIC literature, in part owing to varying quality of data collection in LMICs. Robust population-based surveys are needed to accurately estimate the burden of surgically correctable congenital anomalies in LMICs. LEVEL OF EVIDENCE: Level V, expert opinion without explicit critical appraisal.
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Anomalías Congénitas/epidemiología , Países en Desarrollo , Humanos , Incidencia , Pobreza , PrevalenciaRESUMEN
BACKGROUND: The Lancet Commission on Global Surgery highlighted global surgical need but offered little insight into the specific surgical challenges of children in low-resource settings. Efforts to strengthen the quality of global pediatric surgical care have resulted in a proliferation of partnerships between low-and middle-income countries (LMICs) and high-income countries (HICs). Standardized tools able to reliably measure gaps in delivery and quality of care are important aids for these partnerships. We undertook a systematic review (SR) of capacity assessment tools (CATs) focused on needs assessment in pediatric surgery. METHODS: A comprehensive search strategy of multiple electronic databases was conducted per PRISMA guidelines without linguistic or temporal restrictions. CATs were selected according to pre-defined inclusion criteria. Articles were assessed by two independent reviewers. Methodological quality of studies was appraised using the COSMIN checklist with 4-point scale. RESULTS: The search strategy generated 16,641 original publications, of which three CATs were deemed eligible. Eligible tools were either excessively detailed or oversimplified. None used weighted scores to identify finer granularity between institutions. No CATs comprehensively included measures of resources, outcomes, accessibility/impact and training. DISCUSSION: The results of this study identify the need for a CAT capable of objectively measuring key aspects of surgical capacity and performance in a weighted tool designed for pediatric surgical centers in LMICs. TYPE OF STUDY: Systematic Review. LEVEL OF EVIDENCE: II.
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Salud Global/normas , Evaluación de Necesidades , Mejoramiento de la Calidad , Especialidades Quirúrgicas/normas , Niño , Recursos en Salud , Humanos , Pediatría/normas , PobrezaRESUMEN
PURPOSE: Prolonged central vascular access is a source of significant morbidity in children with intestinal failure (IF). In an effort to decrease morbidity, our multidisciplinary IF team has primarily used peripherally inserted central catheters (PICCs) for these patients. We compared outcomes of PICCs to Broviacs®. METHODS: A review of children with IF (2006-2018) at an academic children's hospital was conducted. INCLUSION CRITERIA: total parenteral nutrition duration >42â¯days or small bowel lengthâ¯<â¯25% of total for gestational age. Complications/1000 catheter days were extracted, and a Poisson model was used to compare complications between PICCs and Broviacs®. RESULTS: Thirty-seven patients with IF were included, accounting for 19,452 catheter days. There were 209 PICCs (1.2-4F) and 39 Broviacs® (2.7-7F). The median duration of overall PICC access/patient was 166â¯days (range: 35â¯days-8â¯years). Incidences of central line associated blood stream infection and venous thrombosis were 3.95 and 0.55 per 1000 catheter days, respectively. There were no significant differences in complication rates per line per catheter day between PICCs and Broviacs® on multivariate analysis. Broviacs® showed a trend towards increased of catheter-related hospital admissions when compared to PICCs. CONCLUSIONS: PICCs in children with intestinal failure have similar complication rates to Broviacs® but may reduce catheter-related hospital admissions. Use of tunneled PICCs and increasing experience with this vascular access method may allow it to realize its potential advantages. LEVEL OF EVIDENCE: Retrospective study, level III.
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Cateterismo Venoso Central/métodos , Cateterismo Periférico/métodos , Catéteres Venosos Centrales , Enfermedades Intestinales/terapia , Infecciones Relacionadas con Catéteres/epidemiología , Cateterismo Venoso Central/efectos adversos , Cateterismo Venoso Central/instrumentación , Cateterismo Periférico/efectos adversos , Cateterismo Periférico/instrumentación , Catéteres Venosos Centrales/efectos adversos , Femenino , Humanos , Lactante , Masculino , Análisis Multivariante , Nutrición Parenteral Total , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
INTRODUCTION: Parental presence at induction of general anesthesia (PPI) is highly desired by children and parents. However, it often faces resistance from medical personnel. We conducted a survey evaluating the perceptions of surgeons before and after establishment of a PPI program. METHODS: Internal web-based surveys using Likert Scale questions were administered to all members of a pediatric surgical department before and after the introduction of PPI at a freestanding children's hospital. Pre and post results were compared by Wilcoxon rank-sum tests. A p-value ≤0.0026 was considered significant due to the Bonferroni correction. RESULTS: The survey was sent to 59 surgeons 1year before and 5years after gradual implementation of PPI. Response rates were 46% and 54%, pre and post implementation, respectively. After implementation, there was a statistically significant increased level of agreement with the statement: "PPI improves the parents' level of satisfaction" (p=0.0025) and a statistically significant decreased level of agreement with the statement "PPI lengthens the duration of induction" (p=0.0001). Before initiation, 56% wanted to see PPI implemented, while after implementation, 97% wanted PPI to remain. CONCLUSIONS: A majority of pediatric surgeons favored maintaining PPI after implementation. Resistance to initiation of PPI should not hinder implementation. TYPE OF STUDY: Survey LEVEL OF EVIDENCE: Not applicable.
Asunto(s)
Anestesia General/psicología , Implementación de Plan de Salud , Padres/psicología , Cooperación del Paciente/psicología , Cuidados Preoperatorios/métodos , Anestesia General/métodos , Ansiedad/prevención & control , Niño , Femenino , Humanos , Relaciones Padres-Hijo , Encuestas y CuestionariosRESUMEN
BACKGROUND: The Lancet Commission on Global Surgery reported that 5 billion people lack access to safe, affordable surgical care. The majority of these people live in low-resource settings, where up to 50% of the population is children. The Disease Control Priorities (Debas HTP, Donkor A, Gawande DT, Jamison ME, Kruk, and Mock CN, editors. Essential Surgery. Disease Control Priorities. Third Edition, vol 1. Essential Surgery. Washington, DC: World Bank; 2015) on surgery included guidelines for the improvement of access to surgical care; however, these lack detail for children's surgery. AIM: To produce guidance for low- and middle-income countries (LMICs) on the resources required for children's surgery at each level of hospital care. METHODS: The Global Initiative for Children's Surgery (GICS) held an inaugural meeting at the Royal College of Surgeons in London in May 2016, with 52 surgical providers from 21 countries, including 27 providers from 18 LMICs. Delegates engaged in working groups over 2 days to prioritize needs and solutions for optimizing children's surgical care; these were categorized into infrastructure, service delivery, training, and research. At a second GICS meeting in Washington in October 2016, 94 surgical care providers, half from LMICs, defined the optimal resources required at primary, secondary, tertiary, and national referral level through a series of working group engagements. RESULTS: Consensus solutions for optimizing children's surgical care included the following: · Establishing standards and integrating them into national surgical plans.. · Each country should have at least one children's hospital.. · Designate, facilitate, and support regional training hubs covering all. · children's surgical specialties.. · Establish regional research support centers.. An "Optimal Resources" document was produced detailing the facilities and resources required at each level of care. CONCLUSION: The Optimal Resources document has been produced by surgical providers from LMICs who have the greatest insight into the needs and priorities in their population. The document will be refined further through online GICS Working Groups and the World Health Organization for broad application to ensure all children have timely access to safe surgical care.
Asunto(s)
Países en Desarrollo , Accesibilidad a los Servicios de Salud/normas , Hospitales Pediátricos/normas , Pediatría/normas , Mejoramiento de la Calidad/normas , Especialidades Quirúrgicas/normas , Procedimientos Quirúrgicos Operativos/normas , Niño , Salud Global , Asignación de Recursos para la Atención de Salud/organización & administración , Accesibilidad a los Servicios de Salud/organización & administración , Hospitales Pediátricos/provisión & distribución , Humanos , Pediatría/educación , Pediatría/organización & administración , Especialidades Quirúrgicas/educación , Especialidades Quirúrgicas/organización & administración , Procedimientos Quirúrgicos Operativos/educaciónRESUMEN
PURPOSE: Despite a wide spectrum of severity, perforated appendicitis in children is typically considered a single entity in outcomes studies. We performed a prospective cohort study to define a risk stratification system that correlates with outcomes and resource utilization. METHODS: A prospective study was conducted of all children operated for perforated appendicitis between May 2015 and December 2016 at a tertiary free-standing university children's hospital. Surgical findings were classified into one of four grades of perforation: I. localized or contained perforation, II. Contained abscess with no generalized peritonitis, III. Generalized peritonitis with no dominant abscess, IV. Generalized peritonitis with one or more dominant abscesses. All patients were treated on a clinical pathway that involved all points of care from admission to final follow-up. Outcomes and resource utilization measures were analyzed using Fisher's exact test, Kruskal-Wallis test, One-way ANOVA, and logistic regression. RESULTS: During the study period, 122 patients completed treatment, and 100% had documented follow-up at a median of 25days after operation. Grades of perforation were: I, 20.5%; II, 37.7%; III, 10.7%; IV, 31.1%. Postoperative abscesses occurred in 12 (9.8%) of patients, almost exclusively in Grade IV perforations. Hospital stay, duration of antibiotics, TPN utilization, and the incidence of postoperative imaging significantly increased with increasing grade of perforation. CONCLUSION: Outcomes and resource utilization strongly correlate with increasing grade of perforated appendicitis. Postoperative abscesses, additional imaging, and additional invasive procedures occur disproportionately in patients who present with diffuse peritonitis and abscess formation. The current stratification allows risk-adjusted outcome reporting and appropriate assignment of resource burden. LEVEL OF EVIDENCE: I (Prognosis Study).