Neonatal Surgical Conditions Research Articles

Neonatal Surgical Conditions in Uganda and the United States: Disparities and Economic Benefit of Scaling Up Care

Background: The burden of congenital anomalies is disproportionally shouldered by low and middle-income countries (LMICs) where 94% of these defects occur. In Uganda, only 4 pediatric surgeons serve a population of 20 million children. We compare the distribution and mortality of common neonatal surgical conditions between Uganda and the United States. We also estimate potential economic benefit of scaling up neonatal surgical care in …

Neonatal Surgical Conditions in Uganda and the United States: Disparities and Economic Benefit of Scaling Up Care

Neonatal Surgical Conditions in Uganda and the United States: Disparities and Economic Benefit of Scaling Up Care

An analysis of neonates with surgical diagnoses admitted to the neonatal intensive care unit at Charlotte Maxeke Johannesburg Academic Hospital, South Africa.

The burden of neonatal surgical conditions is not well documented in low- to middle-income countries (LMICs). These conditions are thought to be relatively common, with a considerable proportion of neonates admitted to the neonatal intensive care unit (NICU) requiring surgical intervention. To review neonates with surgical conditions admitted to the NICU in our hospital setting. This was a retrospective, descriptive study of neonates with surgical conditions admitted to the NICU at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH), South Africa, between 1 January 2013 and 31 December 2015. The characteristics and survival of these neonates were described using univariate analysis. The NICU at CMJAH is combined with a paediatric intensive care unit, to a total of 15 beds, and serves as a referral unit. Of 923 neonates admitted to the NICU, 319 (34.6%) had primarily surgical conditions. Of these 319 neonates, 205 survived (64.3%). There were 125/319 neonates (39.2%) with necrotising enterocolitis (NEC), 55 of whom survived (55/125; 44.0%), making the presence of NEC significantly associated with poor outcome (p<0.001). Other significant predictors of poor outcome were the patient being outborn (p=0.029); the presence of late-onset sepsis (p<0.001), with Gram-negative organisms (p=0.005); and lesser gestational age (p=0.001) and lower birth weight (p<0.001). Major birth defects were present in 166/319 neonates (52.0%). The abdomen was the most prevalent site of surgery, with 216/258 procedures (83.7%) being abdominal, resulting in a mortality rate of 76/216 (35.2%). Neonates with major surgical conditions accounted for one-third of NICU admissions in the present study. The study highlights the considerable burden placed on paediatric surgical services at a large referral hospital in SA. Paediatric surgical services, with early referral and improvement of neonatal transport systems, must be a priority in planned healthcare interventions to reduce neonatal mortality in LMICs.

Burden of Neonatal Surgical Conditions in Northern Ghana

BackgroundCongenital anomalies have risen to become the fifth leading cause of under-five mortality globally. The majority of deaths and disability occur in low- and middle-income countries including Ghana. This 3-year retrospective review aimed to define, for the first time, the characteristics and outcomes of neonatal surgical conditions in northern Ghana.MethodsA retrospective study was conducted to include all admissions to the Tamale Teaching Hospital (TTH) neonatal intensive care unit (NICU) with surgical conditions between January 2014 and January 2017. Data were collected on demographics, diagnosis and outcomes. Descriptive analysis was performed on all data, and logistic regression was used to predict determinants of neonatal mortality. p < 0.05 was deemed significant.ResultsThree hundred and forty-seven neonates were included. Two hundred and sixty-one (75.2%) were aged 7 days or less at presentation, with males (n = 177, 52%) slightly higher than females (n = 165, 48%). The majority were delivered by spontaneous vaginal delivery (n = 247, 88%); 191 (58%) were born in hospital. Congenital anomalies accounted for 302 (87%) of the neonatal surgical cases and 45 (96%) deaths. The most common anomalies were omphalocele (n = 48, 13.8%), imperforate anus (n = 34, 9.8%), intestinal obstruction (n = 29, 8.4%), spina bifida (n = 26, 7.5%) and hydrocephalus (n = 19, 5.5%). The overall mortality rate was 13.5%. Two-thirds of the deaths (n = 30) from congenital anomalies were conditions involving the digestive system with gastroschisis having the highest mortality of 88%. Omphalocele (n = 11, 23.4%), gastroschisis (n = 7, 14.9%) and imperforate anus (n = 6, 12.8%) contributed to the most deaths. On multivariate analysis, low birthweight was significantly associated with mortality (OR 3.59, CI 1.4–9.5, p = 0.009).ConclusionCongenital anomalies are a major global health problem associated with high neonatal mortality in Ghana. The highest burden in terms of both caseload and mortality is attributed to congenital anomalies involving the digestive system, which should be targeted to improve outcomes.

Burden and Outcomes of Neonatal Surgery in Uganda: Results of a Five-Year Prospective Study

BackgroundNinety-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. MethodsA 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. ResultsFor 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. ConclusionsNeonatal 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.

Outcomes of neonates requiring surgical interventions in Eldoret

Background: Neonatal surgical conditions account for 11% of the Global Burden of Diseases (GBD); neglect of their management has been reported though most are amenable to surgery. Timely surgical interventions play a major role in determining better outcomes, thus improving quality of life and reducing disability. Several factors—sepsis control, care in newborn intensive care unit and availability of total parenteral nutrition—have been shown to improve the outcomes of neonates with surgical conditions. Objective: To evaluate the outcomes of neonates with conditions requiring surgical interventions. Methods: A prospective descriptive study in the Newborn Unit, Moi Teaching and Referral Hospital (MTRH). Data on the following study variables were obtained and analyzed: maternal age, place and mode of delivery, newborn’s age at admission, birth weight, surgical condition, co-morbid conditions, treatment outcomes (discharge, death or referral to Kenyatta National Hospital for specialized care), surgical complications, time-to-initiation of oral feeds post-operatively, antenatal history and laboratory parameters; and length of hospital stay. Results: A total of 124 neonates were recruited; male to female ratio was 1.1:1 and median age at admission was 2 days (IQR 1, 5). Most (59.7%) were in the birth weight range of 2.5–3.9 kg. The leading neonatal surgical conditions were gastroschisis 33(26.6%), neural tube defects 25(20.2%) and ARM 25(20.2%). Overall mortality rate was 31.5%. Antenatal clinic attendance was associated with decreased odds of mortality (OR 0.126; 95% CI 0.025–0.6429; p=0.013), while neonatal sepsis, respiratory distress and electrolyte imbalance were associated with increased odds of mortality ([OR 3.4; 95% CI 1.09–22.06; p=0.049], [OR 4.9; CI 0.91–11.61; p=0.001] and [OR 3.1; CI 1.21–31.60; p=0.029], respectively). Conclusions: The overall mortality rate of neonates requiring surgical interventions at MTRH was 31.5% and the median length of hospital stay was 14.5 days. Co-morbid conditions that increased the odds of mortality among these neonates were neonatal sepsis, respiratory distress and electrolyte imbalance. Keywords: Neonates, Surgical, Interventions, Outcomes

Necrotising enterocolitis and point of care neonatal abdominal USS

Neonatal intensive care has seen dramatic improvements over last four decades in rates of survival for most preterm newborns. Limits of survival were generally regarded 27 weeks gestation in the 80’s, are now 23 weeks gestation. These micro-premies are much smaller (500 to 800 grams birth weight) and are now increasingly managed with nasal continuous positive airway pressure as respiratory support. Acute abdominal emergencies are common in these infants and can be difficult to distinguish from dysmotile intestinal function in early stages. Preterm infants treated with nasal continuous positive airway pressure often have distended abdomens with feed intolerance requiring evaluation for potentially life-threatening conditions such as necrotising enterocolitis. Plain abdominal radiography is the gold standard modality for diagnosis, monitoring and guiding management in clinically suspected diseased neonatal bowel states. Timely access of expert surgical opinion poses frequent dilemmas of transporting a critically ill preterm infant to a surgical facility. There is compelling evidence demonstrating diagnostic bowel ultrasound findings in necrotising enterocolitis by trained medical ultrasonographers. There is a growing interest in utility of performing bowel ultrasound amongst point-of-care neonatal clinicians. Despite technical challenges, point-of-care bowel ultrasound has the added ability to measure bowel wall thickness, provide real-time evaluation of bowel peristalsis, perfusion, detection of free abdominal fluid; in addition to detection of pneumatosis intestinalis, portal venous gas and pneumoperitoneum like plain abdominal radiographs. This provides a more complete understanding of bowel state. Specific color doppler bowel wall arterial flow patterns have been described in necrotising enterocolitis, as “zebra”, “Y” and the “ring” patterns corresponding to inflamed viable bowel. Bowel ultrasound is more sensitive than abdominal radiography in the detection of pneumotosis intestinalis in early stages of necrotising enterocolitis. As the disease progresses, the visualization of thinned bowel wall with lack of bowel wall perfusion on ultrasound implies nonviable bowel with impending perforation. Detection of this bowel state early is valuable in the clinical management as pneumoperitoneum suggesting bowel perforation on plain abdominal radiograph is a late sign. Rarer diagnoses with acute neonatal surgical conditions can also be assessed with the use of bowel ultrasound such as malrotation. With widening of knowledge and appropriate training in ultrasound techniques, neonatologists will be able to enhance their diagnostic acumen by performing point-of-care bowel ultrasound in addition to plain radiography for a broad array of diseased bowel states in neonates.

Uneven learning patterns in preschool children with high risk neonatal medical and surgical conditions

Uneven learning patterns in preschool children with high risk neonatal medical and surgical conditions

A 3 years’ Experience of Operated Surgical Neonates Outcome in a Tertiary Hospital of Ain Shams University (Neonatal Intensive Care Unit)

Background: Surgery on a newborn has been one of the most challenging subjects in medical science. A neonate is born with its unique physiological features of very narrow normal ranges, beyond which it is helpless to cope with the adverse situations. Added to this, it has to be able to respond to life-threatening surgical conditions for its survival. Objectives: We aimed in this piece of work to assess the outcome of different neonatal surgical conditions and factors responsible for mortality in surgical neonates. Patients and Methods: The present retrospective study was conducted in the NICU of Ain Shams University Children’s Hospital using the records from the beginning of year 2011 till the end of year 2013. The recorded data included gestational age, postnatal age at admission, sex of neonates, maternal age, mode of delivery, surgical diagnosis, surgery outcome, risk factors for occurrence of sepsis, classification of type of sepsis if present (Early-onset sepsis, Late-onset, or nosocomial) , blood culture results, antimicrobials used, length of hospital stay, need for ventilation, risk factors for occurrence of sepsis, cause of death. Results: The study included 69 patients with surgical problems who were admitted to the NICU. They were 45 males (65.22%) and 24 females (34.78%) with a male to female ratio of 1.8: 1. They were 10 preterms (14.49%) and 59 full-terms (85.51%); with mean gestational age range from 32-40 weeks, mean ± SD: 36.91±1.98 weeks. 37 (53.62%) were delivered by LSCS and 32 (46.38%) by SVD. 33.33% of neonates were admitted between 1 and 2 days postnatal, 42.9% were more than 1 week old, with mean age of admission 9.49 ±10.37 days. The most common surgical problems were Tracheo-oesophageal fistula (9 cases), followed by imperforate anus low anomaly 5 cases, imperforate anus high anomaly 5 cases, then Hirshsprung disease 4 cases. Also hydrocephalus and Arnold Chiari malformation each 4 cases. Diaphragmatic hernia 4 cases. 61 cases had sepsis, 50 cases were discharged, 19 died and 8 had no complications. The most common causes of death were; sepsis (16 cases), heart failure (9 cases), respiratory failure (5 cases), cardio –pulmonary failure (3 cases) and pneumonia and pulmonary hypertension each one case. Conclusion: Most of cases were full term babies and had late presentation to our hospital which led to delayed operations. Most common surgical problem was trachea-oesophageal fistula.

Centralized Pediatric Surgery in the Nordic Countries: A Role Model for Europe?

AbstractNearly all neonatal surgical conditions are classified as rare diseases in Europe. Due to rapidly developing treatment modalities and novel surgical techniques, as well as increasing demands from patients, there is a growing need for centralization of advanced pediatric surgical care. However, the optimal way to concentrate pediatric surgical experience in each country remains unclear and depends on multiple national features, such as size and distribution of the population, geographical distances, local surgical expertise, organization of the health care system, and political agendas. This review outlines the current practices to concentrate on specialized pediatric surgery in different Nordic countries.

Minimal Access Surgery in Neonates.

Despite the significant advancement of minimally invasive surgery (MIS) in the adults and even in pediatric population, its role as the standard of care in the neonates has not yet been established among the pediatric and neonatal surgeons universally. Lots of controversies still arise though several advanced centers in the world having very experienced surgeons performing MIS for neonatal surgical conditions with promising outcomes. The unique physiological characteristics of a neonate make MIS quiet a challenging subject among these tiny babies. We have tried to look into the recent literature on the issues related to the use of MIS for the surgical management of neonates.

Enterostomy-related complications and growth following reversal in infants

BackgroundInfant enterostomies are used to manage various neonatal surgical conditions where it is not suitable or safe to form a primary anastomosis. Complications are common and there is no consensus...

Minimally Invasive Surgery in Neonatal Patients: A Review

Laparoscopic and thoracoscopic surgery have gradually become accepted diagnostic and therapeutic modalities in the management of neonatal surgical conditions. In the hands of experienced surgeons, minimally invasive surgery (MIS) has reduced the need for open procedures. In children younger than 1 year, the advantages of MIS are evident in avoiding the sequelae of open surgery. MIS has shown outcomes comparable to those with open surgery. The recent literature in the PubMed database was reviewed, using the keywords “minimally invasive surgery,” “neonatology,” “pediatric surgery,” “laparoscopy,” and “thoracoscopy.” The review included retrospective and institutional reports of MIS published since January 2000.The results were used to develop a review of the current state of MIS in the neonatal population. The use of minimally invasive techniques in neonatal surgical conditions was successful in the hands of experienced surgeons. Some procedures currently performed include gastrostomy, pyloromyotomy for hypertrophic pyloric stenosis, gastroesophageal reflux surgery, the Ladd procedure for intestinal malrotation, colonic pull-through procedures for Hirschsprung disease and other anorectal malformations, repair of diaphragmatic eventration and congenital diaphragmatic hernia, duodenal atresia, esophageal atresia/tracheoesophageal fistula, pulmonary lobectomy, surgery for necrotizing enterocolitis, and ligation of patent ductus arteriosus. Further formal training of surgeons in these techniques and the development of new and improved instrumentation can reduce the rates of open surgery and its sequelae in the neonatal population.

Publication patterns on neonatal surgery over 65 years

Background/PurposeStaying abreast of the literature in a given speciality is difficult. The aim of this study is to analyze the publication patterns of the neonatal surgical literature over the last six decades. MaterialsA search strategy for the Web of Science database was designed using MeSH defined terms for 10 index neonatal surgical conditions, with output analyzed over two time-periods. ResultsThere were 6215 and 6144 publications for periods 1 (1945–1994) and 2 (1995–2010), respectively. There were 24 and 546 articles published in 1945 and 2010, respectively. The mean citation counts of the top 50 publications are 228 and 156 for periods 1 and 2, respectively. There were 6 and 11 authors with two or more publications in the top 50 list in periods 1 and 2, respectively. Three of the pediatric surgery journals cumulatively have published 30.9% of the total articles. ConclusionsPublication patterns for neonatal surgical conditions have changed significantly over time. The majority of articles are published outside of pediatric surgical journals. Pediatric surgeons should not limit their reading to these journals.

Pattern, outcome and challenges of neonatal surgical cases in a tertiary teaching hospital

Globally, the major causes of neonatal deaths are birth asphyxia, prematurity and severe infections. Little attention is paid to deaths contributed by surgically amenable conditions. This study was undertaken to determine the burden and types of surgical problems encountered in the neonatal period, their outcome and challenges encountered. This was a retrospective study. The case notes of all neonates admitted into the newborn unit of our centre between April 2002 and March 2010 with surgical conditions were retrieved and the following information extracted: Sex, diagnosis, age at presentation, surgical intervention and outcome. Out of 7,401 neonates admitted within the study period, 460 (6.2%) had a surgical condition. Of the 1,657 babies that died within the same period, 196 (11.8%) of them were those with surgical conditions. Congenital abnormalities accounted for 408 (88.7%) of all the surgical cases. Intestinal obstruction 129 (31.6%), neural tube defects 101 (24.8%) and anterior abdominal wall defect 58 (14.2%) were the commonest congenital abnormalities, while fracture of the long bones following birth trauma 15 (28.8%) and perforated NEC 14 (26.9%) were the commonest acquired conditions. Surgery was performed in 166 (36.1%) and 98 (59%) had postoperative complications. Significantly, more deaths occurred in preterms than in term babies (P = 0.003) and in those delivered outside the hospital than in in-born babies (P = 0.02). The major cause of death was infection in 92 (47%). Neonatal surgical conditions contributed significantly to both neonatal admissions and overall neonatal mortality and thus highlights the need for investments in newborn surgical care in developing countries.

Cytomegalo Virus as a Possible Risk Factor for Neonatal Gastrointestinal Surgical Conditions

The present work aims to evaluate the possible causal relationship between CMV infection and gastrointestinal surgical conditions in the neonates. 33 neonate operated on because of gastrointestinal surgical conditions in Assiut University Children Hospital. Detection of CMV IgG and IgM from both mother and newborn was done. Surgical specimen was taken for pathologic examination. Positive serological tests (CMV IgM) were found only in four neonates (3 males and one female). Maternal CMV IgM were positive only in two cases. All surgical specimens showed characteristic CMV nuclear inclusion bodies.

Role of echocardiography in management of shock

Neonatal shock frequently complicates extremely preterm delivery, severe respiratory distress, asphyxia and sepsis. Early recognition and rapid targeted treatment are essential. Echocardiographic assessment is required to differentiate between infants with high and low systemic vascular resistance. Echocardiography assesses structural normality of the heart, the presence of shunts across the adapting heart, the pulmonary circulation, cardiac filling and myocardial contractility although measures of cardiac filling and myocardial contractility are poorly validated in newborn infants. SVC flow is the best surrogate of systemic blood flow (SBF) in infants with an atrial or ductal shunt, with LVO or RVO used as a cross-check or in infants with no evidence of shunt. Hypovolaemia is infrequent but may complicate peripartum fetal blood loss or neonatal surgical conditions (eg necrotising enterocolitis) and sepsis. Volume expansion and inotropes should be selected for their desired effect on pulmonary and systemic circulations and titrated to clinical and echocardiographic evidence of response - improvements in oxygenation, BP, pulmonary and SBF. Further studies are required to determine the appropriate targets (blood pressure or SBF) of treatment and treatment thresholds.

Outpatient Practice: Surgical Conditions

Although neonatal surgical emergencies constitute a large part of pediatric surgical practice, there are several surgical conditions and lesions in the newborn that are assessed in the outpatient clinic. Quite frequently, the first clinician to whom such patients are brought by the parents is the pediatrician. The parents are usually very anxious and worried about their child's condition. It is, thus, very important that pediatricians should be sufficiently aware and have enough knowledge about the diagnosis and management of these conditions so that the parents can be counseled and given appropriate advice, especially regarding the referral to a pediatric surgeon or other surgical specialist. This review article discusses the presentation and diagnosis of common neonatal surgical conditions that may be seen by a pediatrician in his outpatient practice. The broad principles of management, especially the timing, if required, of surgical intervention areoutlined.

PS05 LONG‐TERM OUTCOMES IN NEONATAL SURGERY

Historically, for good reason, the main measures used to assess outcome after neonatal surgery have been mortality and early postoperative morbidity. These remain crucial yardsticks of surgical care. However, as results have steadily improved more refined indicators of outcome are needed. Long‐term results and quality of life outcomes are being demanded increasingly by clinicians, parents, and health economists.For paediatric surgeons, knowledge of long‐term outcomes not only enable us to inform parents and patients better about future health expectations but also help us to anticipate potentially avoidable late complications. Outcomes inform us when to operate and when not to operate. Some neonatal surgical conditions and their treatment have almost no long‐term sequelae but most have definite consequences of variable severity.Common themes run through the analysis of long‐term outcomes. These centre around the future impact on growth, risk of malignancy, psychological issues, implications for fertility, sexuality and inheritance, and quality of life. There are many reasons why long‐term data are lacking. These include the difficulties of maintaining long‐term surveillance within healthcare systems overstretched by lack of manpower and funding. Problems of continuity are exacerbated by geographic mobility in society. Robust long‐term studies require careful data collection over many years, the co‐operation of ex‐patients, and familiarity with tools such as independent quality of life measures not readily accessible to paediatric surgeons.Only by addressing long‐term outcomes will the true impact of neonatal surgical conditions be fully understood.

Cytomegalovirus infection as a possible underlying factor in neonatal surgical conditions

Background The seroprevalence of cytomegalovirus (CMV) in France is about 38%. Fetal contamination during pregnancy is 40%. We report a series of gastrointestinal conditions associated with CMV in neonates. Patients and method This is a retrospective study on neonates operated on for gastrointestinal conditions in our institution between January 1998 and December 2002. Only children with suspected CMV infection (characteristic nuclear inclusions) on pathologic examination were reviewed. We analyzed the age of onset, the clinical and radiologic presentation, and the serologic findings in mother and child. Results The study included 3 boys and 2 girls. The average gestational age was 34.4 weeks (range, 28-39 weeks) and the average birth weight was 2364 g (range, 790-3580 g). Two infants had necrotizing enterocolitis, 2 had pathologic condition related to Meckel's diverticulum (volvulus and perforation, respectively), and 1 had distal ileal atresia. All surgical specimens showed characteristic CMV nuclear inclusions. Maternal serologic studies were positive for CMV in only 1 case with CMV IgM detected in serum. Two babies had a positive serological finding for CMV with detection of CMV IgM, and 2 had CMV isolated on urinary viral culture (one had both). Conclusion Cytomegalovirus is a viral agent that may be involved in surgical pathology in neonates. To confirm the causal relationship between CMV and these pathologic findings, a large-scale longitudinal prospective screening of CMV in neonates with intestinal conditions should be performed.