Pediatric Surgical Conditions Research Articles

A review of twenty-first century developments in paediatric surgery in Africa.

This review explores the significant advancements in paediatric surgery in Africa during the twenty-first century, with a particular focus on capacity-building, education, infrastructural development, and research. Historically, paediatric surgery has been an overlooked sector, especially in low-and-middle-income countries in Africa. However, recent years have seen considerable progress. Collaborative efforts such as the Global Initiative for Children's Surgery, and the formation of the Pan African Paediatric Surgery Association, the College of Surgeons of East, Central and Southern Africa and the West African College of Surgeons have facilitated knowledge sharing, collaboration, and advocacy for enhancing surgical standards. Local training programmes, including Master of Medicine programmes and fellowships, have been instrumental in building a skilled workforce. These initiatives have been complemented by infrastructural developments through non-governmental organisations like Kids Operating Room, which have expanded access to paediatric surgical care. Technological advancements, particularly in telemedicine, have further enhanced accessibility. Task-sharing strategies, where non-specialist physicians are trained in paediatric surgical skills, have also been utilised to address the shortage of specialised surgeons. Research in paediatric surgery has experienced an upswing, with local health professionals taking the lead. Research has been crucial for understanding the epidemiology of paediatric surgical conditions, and developing prevention strategies, and is increasingly leading to the inclusion of paediatric surgery in national health plans. Despite the progress, challenges remain, including the need for sustainable funding, continued investment in infrastructure, and training and retention of healthcare professionals. The review emphasises the importance of ongoing efforts in community engagement, innovative technologies, and health systems strengthening for the sustainable development of paediatric surgical services in Africa.

Paediatric testicular torsion in low- and middle-income countries: an OxPLORE scoping study.

Literature on paediatric surgical conditions in low- and middle-income countries (LMICs) remains limited. As a common emergency, timely treatment of testicular torsion acts as a benchmark of adequate emergency service delivery in paediatric surgery. This scoping study aims to synthesise all existing literature on paediatric testicular torsion in LMICs. A database search was conducted by the OxPLORE global paediatric surgery research group to identify studies containing the terms 'testicular torsion' or 'acute scrotum' originating from LMICs. A thematic analysis was applied to the results of the search and the quality of evidence was appraised for all included articles. This review included 17 studies with 1798 patients. All studies originated from middle-income countries and the majority (76%) had sample sizes smaller than 100 patients. All studies were appraised as providing less than adequate evidence. Included studies identified long delays to treatment and highlighted ongoing debates on the value of scoring systems and Doppler ultrasonography in diagnosing torsion. Major heterogeneity in surgical approaches to treatment of testicular torsion in children was also observed. Literature on paediatric testicular torsion in LMICs is scarce and heterogeneous. Prospective, multi-centre research on the management of this common paediatric surgical emergency is urgently required.

The State of Artificial Intelligence in Pediatric Surgery: A Systematic Review

BackgroundArtificial intelligence (AI) has been recently shown to improve clinical workflows and outcomes - yet its potential in pediatric surgery remains largely unexplored. This systematic review details the use of AI in pediatric surgery. MethodsNine medical databases were searched from inception until January 2023, identifying articles focused on AI in pediatric surgery. Two authors reviewed full texts of eligible articles. Studies were included if they were original investigations on the development, validation, or clinical application of AI models for pediatric health conditions primarily managed surgically. Studies were excluded if they were not peer-reviewed, were review articles, editorials, commentaries, or case reports, did not focus on pediatric surgical conditions, or did not employ at least one AI model. Extracted data included study characteristics, clinical specialty, AI method and algorithm type, AI model (algorithm) role and performance metrics, key results, interpretability, validation, and risk of bias using PROBAST and QUADAS-2. ResultsAuthors screened 8178 articles and included 112. Half of the studies (50%) reported predictive models (for adverse events [25%], surgical outcomes [16%] and survival [9%]), followed by diagnostic (29%) and decision support models (21%). Neural networks (44%) and ensemble learners (36%) were the most commonly used AI methods across application domains. The main pediatric surgical subspecialties represented across all models were general surgery (31%) and neurosurgery (25%). Forty-four percent of models were interpretable, and 6% were both interpretable and externally validated. Forty percent of models had a high risk of bias, and concerns over applicability were identified in 7%. ConclusionsWhile AI has wide potential clinical applications in pediatric surgery, very few published AI algorithms were externally validated, interpretable, and unbiased. Future research needs to focus on developing AI models which are prospectively validated and ultimately integrated into clinical workflows. Level of Evidence2A.

Indocyanine green (ICG) fluorescence-enhanced applications in pediatric surgery

The breadth of pediatric surgical practice and variety of anatomic anomalies that characterize surgical disease in children and neonates require a unique level of operative mastery and versatility. Intraoperative navigation of small, complex, and often abnormal anatomy presents a particular challenge for pediatric surgeons. Clinical experience with fluorescent tissue dye, specifically indocyanine green (ICG), is quickly gaining widespread incorporation into adult surgical practice as a safe, non-toxic means of accurately visualizing tissue perfusion, lymphatic flow, and biliary anatomy to enhance operative speed, safety, and patient outcomes. Experience in pediatric surgery, however, remains limited. ICG-fluorescence guided surgery is poised to address the challenges of pediatric and neonatal operations for a growing breadth of surgical pathology. Fluorescent angiography has permitted intraoperative visualization of colorectal flap perfusion for complex pelvic reconstruction and anastomotic perfusion after esophageal atresia repair, while its hepatic absorption and biliary excretion has made it an excellent agent for delineating the dissection plane in the Kasai portoenterostomy and identifying both primary and metastatic hepatoblastoma lesions. Subcutaneous and intra-lymphatic ICG injection can identify iatrogenic chylous leaks and improved yields in sentinel lymph node biopsies. ICG-guided surgery holds promise for more widespread use in pediatric surgical conditions, and continued evaluation of efficacy will be necessary to better inform clinical practice and identify where to focus and develop this technical resource.

A prospective study to assess the feasibility of single port laparoscopic needle assisted repair of pediatric inguinal hernias

Background: Congenital inguinal hernias are very common paediatric surgical conditions with incidence of 0.8 – 4.4% in children and up to 30% in preterm babies, which occur due to the failure of closure of the processus vaginalis. While the gold standard treatment remains to be open herniotomy, in the last two decades minimally invasive surgeries have revolutionized the hernia surgery and have evolved from 3 port to single port, intracorporeal knotting to extracorporeal knotting and 5 mm camera port to 3 mm camera port with multiple benefits. Methodology: This is a prospective study conducted at a single tertiary care centre over 1 year. All the patients admitted under the Department of Paediatric Surgery, with a clinical and/or radiological diagnosis of inguinal hernia and planned for single port laparoscopic needle assisted repair were included in the study. Data was collected in terms of intra operative finding, duration of procedure, complications, pain and post operative hospital stay. Results: A total of 40 patients were included in the study with a male predominance. Clinically majority were right inguinal hernia which was reducible. Intraoperatively, 7 cases of bilateral hernia were identified which were not detected pre operatively. 2 patients who underwent this procedure had complications and majority of the patients had mild pain. Conclusion: Single port laparoscopic herniotomy is at par with gold standard open herniotomy in the paediatric population. This procedure has better cosmesis, lesser post operative pain, hospital stay and most importantly it could identify occult hernias.

Temporal Trends and Spectrum of Pediatric Surgical Conditions Operated In A Tertiary Care Teaching Hospital In Pakistan

Introduction: Knowing the temporal trends as to when and how many pediatric surgery patients present and are operated on in a newly developed unit is crucial in the allocation of resources and policy making in health care center. Aims & Objectives: The aim of this study is to describe the spectrum and pattern of operated pediatric surgery patients in a newly developed pediatric surgical unit of Pakistan. Place and Duration of Study: This study was conducted at Pardiatric Surgery Unit of Holy Family hospital, Rawalpindi between January 2020 and September 2021. Material & Methods: This was a retrospective descriptive study conducted on all patients that were operated under Pediatric surgery unit over a period of 20-months. Data regarding age, sex, diagnosis, and procedure performed were obtained. Diagnoses were categorized based on organ system. SPSS version 22 was used to perform the data analysis., a p-value of ?0.05 was considered significant. Results:898 procedures were performed in total with a male to female ratio of 2.03:1. Most of the patients fell under 2-8 years of age. Digestive system disorders (164, 18.3%) and genitourinary (377, 42%) made most of the cases observed, with inguinal hernias making up to 15.0% of all cases. Oddsratio was calculated for different variables which showed that male patients , patients with gastrointestinal problems had greater odds of being operated. Conclusion: The expected number of operated cases in a newly developed unit is comparable to other units that have been established for a long time.More focus research needs to be done on different aspects of pediatric surgery in our region and to try for integration of pediatric surgery into public health programs including primary and secondary health centers to meet the increasing demand of pediatric surgical patients presented to tertiary care.

Infantile Hypertrophic Pyloric Stenosis: Review of Pathophysiology, Clinical Presentation, Treatment and Outcomes

Infantile hypertrophic pyloric stenosis (IHPS) is considered one of the most common pediatric surgical conditions. Presentation is most common between the ages of 2 to 12 weeks with a mean and median age of 5 weeks. IHPS has been reported to be more common in males than females (5:1) and in first-born children (30-40%). Throughout history, the etiology of this condition has been studied, discovering multiple genetic and environmental factors, such as newborns with increased acid secretion, nitric oxide synthase deficiency, poor innervation of the pyloric muscle, smoking during pregnancy, neonatal use of macrolides and cesarean section; however, the exact cause remains uncertain. The classic clinical presentation begins with a recent history of severe, nonbilious projectile vomiting immediately after feeding and a strong, persistent appetite. During abdominal examination, palpation of the "pyloric olive" in the epigastrium by an experienced doctor is considered a pathognomonic sign. Laboratory tests may show low chloride, potassium, and hydrogen ion levels, leading to metabolic alkalosis due to persistent vomiting. Ultrasound is the gold standard imaging study if history and physical examination are insufficient to diagnose IHPS with a reported sensitivity and specificity of up to 98% and 100% by allowing evaluation of pyloric morphology and behavior. Pyloromyotomy is considered the definitive treatment for infantile hypertrophic pyloric stenosis, but should not be performed until the baby is adequately resuscitated. Patients typically experience positive outcomes after pyloromyotomy, with low morbidity and mortality rates. Most cases recover quickly and without complications.

Implementation of Standardized Educational Material in Outpatient Pediatric Surgery: A Pilot Study

IntroductionCaregiver health literacy is affected by both personal knowledge and education provided by clinicians. Literature on implementation of educational materials into pediatric surgical clinical practice is scarce. We developed plain-language picture-based educational material and implemented it in a pediatric surgery clinic. We assessed both caregiver and clinician satisfaction before and after implementation. MethodsPicture-based educational material was developed for epigastric/umbilical/inguinal hernias/hydroceles, gastrostomy/gastrojejunostomy tube creation, and soft tissue masses and implemented in an academic pediatric surgery clinic. Pediatric surgeons (n = 12), clinic nurses (n = 4), and physician extenders (n = 2) were surveyed before and after a 4-week pilot implementation period. In parallel, parents of children (0-18 y) completed a 19-item postpre electronic survey capturing demographics, self-professed level of prior knowledge, and opinions regarding the material. Descriptive statistics were performed. ResultsClinician response rate was 88% (pre) and 72% (post). Preimplementation, clinicians overwhelmingly reported repetitive parental counseling, need to redraw diagrams, and anticipation of improvement in workflow with standardized materials. Postimplementation, most clinicians felt the material was easy to use (76%), beneficial (77%), and perceived satisfaction in parents they were counseling (77%). Caregiver response rate was 100%. The majority reported their understanding improved after reviewing the material, found the material easy to understand and helpful, were more comfortable managing their child's condition, and recommended continued use of the material during visits. ConclusionsResults indicate clinician satisfaction and willingness to use standardized educational material during outpatient visits, as well as caregiver satisfaction and self-reported improved understanding. These findings support further development and use of standardized educational material for pediatric surgical conditions and procedures.

The Pediatric Emergency Surgery Course: Impact on Provider Practice in Rural Uganda

PurposeThe Pediatric Emergency Surgery Course (PESC) trains rural Ugandan providers to recognize and manage critical pediatric surgical conditions. 45 providers took PESC between 2018 and 2019. We sought to assess the impact of the course at three regional hospitals: Fort Portal, Kabale, and Kiwoko. MethodsWe conducted a retrospective cohort study. Diagnosis, procedure, and patient outcome data were collected twelve months before and after PESC from admission and theater logbooks. We also assessed referrals from these institutions to Uganda's two pediatric surgery hubs: Mulago and Mbarara Hospitals. Wilcoxon rank-sum and Pearson's chi-squared tests compared pre- and post-PESC measures. Interrupted time-series-analysis assessed referral volume before and after PESC. Results1534 admissions and 2148 cases were documented across the three regional hospitals. Kiwoko made 539 referrals, while pediatric surgery hubs received 116 referrals. There was a statistically significant immediate increase in the number of referrals from Fort Portal, from 0.5 patients/month pre-PESC to 0.8 post-PESC (95 % CI 0.03–1.51). Moving averages of the combined number of pyloromyotomy, intussusception reductions, and hernia repairs at the rural hospitals also increased post-course. Neonatal time to referral and referred patient age were significantly lower after PESC delivery. ConclusionOur data suggest that PESC increased referrals to tertiary centers and operative volume of selected cases at rural hospitals and shortened time to presentation at sites receiving referrals. PESC is a locally-driven, validated, clinical education intervention that improves timely care of pediatric surgical emergencies and merits further support and dissemination. Type of StudyRetrospective Cohort Study. Level of EvidenceIII.

Cost-effectiveness analysis of robot-assisted laparoscopic surgery for complex pediatric surgical conditions.

Robotics has been used safely and successfully in a variety of adult surgeries and is gradually gaining ground in pediatrics. While the benefits of robotic-assisted surgery in disease treatment are well recognized, its high cost has led to questions. To investigate whether robotic-assisted laparoscopic surgery (RALS) is cost-effective compared to conventional laparoscopic surgery (LS) in pediatric surgery, we attempted to construct a model to perform an analysis of these two surgical approaches using Python statistical analysis software. We selected four common complex pediatric surgical conditions (choledochal cyst, Hirschsprung's disease, vesicoureteral reflux, and congenital hydronephrosis) from three systems (pediatric hepatobiliary, gastroenterology, and urology). Models were constructed using Python statistical software to compare hospital costs and surgical outcomes for RALS and LS. In addition, we performed a preferred strategy analysis for both surgical modalities while assessing model uncertainty using one-way sensitivity analysis. For the four diseases, the operative time decreased sequentially. The total inpatient costs of RALS were 10,816.72, 9145.44, 8414.29, 7973.58 dollars, respectively, yielding 1.789, 1.712, 1.749, 1.792 quality adjustment life years (QALYs) over two years post-operatively. The incremental cost of RALS relative to LS for each disease was 3523.44, 3200.20, 3049.79, 3043.66 dollars, respectively, with an incremental utility of 0.060, 0.054, 0.051, 0.050 QALYs. The incremental cost-effectiveness ratios (ICERs) for RALS for each of the four diseases were 58,724.01, 59,262.95, 59,799.79, 60,873.20 dollars/QALY, all less than 100,000 dollars/QALY. The cost of robot consumables was the main incremental cost of RALS and had the most significant impact on the model. For the four pediatric surgical conditions described above, RALS has higher inpatient costs than LS, but it has better postoperative outcomes, and all four RALS treatments are cost-effective. Children with complex diseases and long operative times appear to benefit more from RALS.

Establishment of a successful robotic pediatric general surgery practice.

Robotic-assisted surgery (RAS) has a variety of theoretical advantages, including tremor filtration, optimal visualization, and improvement of surgeon ergonomics. Though it has achieved wide application in pediatric urology, the majority of pediatric general surgeons do not employ RAS. This study reports our institution's experience with RAS on a pediatric general surgery team. Following IRB approval, a retrospective review of all pediatric patients at our academic children's hospital who underwent RAS between 2017 and 2022 for pediatric general surgical conditions was performed. Patient demographics, operation performed, operating time, complications, and recovery were evaluated. A total of 159 children underwent RAS, increasing from 10 patients in 2017 to 59 patients in 2022. The median age and weight were 15.3years and 76.4kg, and 121 (76.1%) were female. The application of RAS was successful in all cases. There were no intraoperative complications and no conversions to an open approach. Eleven patients (6.9%) had unplanned presentations to the emergency department within 30days. Five of these patients (3.1%) required admission to the hospital. This study demonstrates that the application of RAS in an academic pediatric general surgery practice is feasible and safe. The application of RAS to pediatric general surgery should continue to increase as operative teams increase their experience and comfort.Level of evidence Level IV.

Virtual Bronchoscopy – An emerging tool to diagnose ‘H’ type Tracheoesophageal Fistula (TEF)

Most of the pediatric surgical conditions or major congenital malformations are diagnosed on spot or with simple radiological imaging just like Tracheoesophageal Fistula (TEF), e.g., Inability to pass NG tube with coiling of NG tube on chest X-ray. But a few of them are still challenging to diagnose, just like ‘H’ type TEF because of delayed presentation as well as absent classical symptoms. (1) And even in today’s era where radiological accuracy has reached to a new level, this diagnosis is missed many times and only confirmed on table. Here we are reporting a case of ‘H’ type TEF, a 17 days old male child, whom we diagnosed on single attempt with virtual bronchoscopy.

Retrospective pattern study of pediatric surgical conditions outcome in a tertiary care center

Aim: To observe the incidence and outcome of pediatric surgical conditions in a tertiary care center. Method: A retrospective observational study was conducted at Motherhood Chaitanya hospital between January, 2018 to December, 2021 and 118 patients requiring surgery were enrolled during the time frame. These cases were divided into congenital and acquired conditions. Incidence of various surgical conditions in different age groups has been observed. The comparison was made as to which condition is predominantly common in the center. Length of hospital stay was taken into consideration and time taken to initiate enteral feeds and reach full feeds was studied in gastrointestinal (GI) cases. The outcome of 118 cases has been assessed in the form of discharge or death. Results: In this study, a total of 118 patients were enrolled over the specified age time frame from birth to 16 years. The majority of the cases were males and the male to female ratio of 2.8:1. 32.2% of the cases were between 4 to 13 years, the age group most commonly affected. 80 cases accounted for congenital anomalies with inguinal hernia being the most common (18.75%). 31.5% were abscesses requiring drainage among acquired conditions. 50% of total cases were gastrointestinal cases with inguinal hernia having a maximum incidence(25.4%). 32.2% of cases had a hospital stay of 24 to 48 hours. Time taken to initiate feeds was 1.5 days in GI surgeries. Mortality of 2.5% has been observed in this study. Conclusion: Pediatric surgery conditions pose a major health and economic burden to the community so they must be timely identified and treated.

Prevalence and outcomes of pediatric surgical conditions at Connaught Hospital in Freetown: a retrospective study

BackgroundSub-Saharan Africa experiences a disproportionate amount of pediatric surgical disease, with 80% of children lacking access to timely, affordable, and safe surgical care. This study aims to characterize the burden...

Double encephalocele: A rare neural tube defect

Abstract Neural tube defects are common pediatric surgical conditions. Among them, encephalocele represents the protrusion of the brain component through the cranial defect. Double encephalocele is a rare entity, with only five cases reported in literature.We report a case of congenital double encephalocele with review of literature.

Determining the Clinical Value of Routine Post Operative follow up in Common Paediatric Surgical Conditions: A Prospective Observational Study.

The traditional postoperative visit consists of an in-person hospital visit at a predetermined date which requires the investment of time and resources. This implies a need to prioritize visits rather than mandating them, which can be assessed by the requirement of clinical intervention at the time of follow-up. The purpose of this study is to determine the clinical value of routine postoperative physical follow-up in common pediatric surgery conditions, to identify factors determining follow-up, and to estimate the cost of routine follow-up. Surgical data of 226 patients admitted for routine pediatric surgical procedures were collected. The postoperative period was documented in detail and interventions done either physically or telephonically at the time of follow-up were used as a proxy measure of clinical value. There were 226 patients enrolled, of which 64.60% followed up physically in outpatient department and 35.40% followed up telephonically. Maximum percentage of patients with postoperative complications belonged to the group of laparotomy at 22.22%, followed by complicated appendicitis at 15.62%. 13.27% of patients required clinical intervention at the time of follow-up. Patients undergoing simpler procedures such as inguinal hernia, hydrocele, and orchidopexy have lesser rate of complications which translates to requirement of fewer clinic visits, whereas those undergoing procedures such as appendectomy and laparotomy require a physical visit after discharge since they are more susceptible to develop complications requiring interventions. By selecting patients for physical visit, we can potentially eliminate unnecessary visits in patients who have low chance of developing complications.

Prevalence of pediatric surgical problems among east African refugees: estimates from a cross-sectional survey using random cluster sampling

ImportanceSurgery is a foundational aspect to high functioning health care systems. In the wake of the Lancet Commission on Global Surgery, previous research has focused on defining the burden of surgical conditions among a pediatric population, however these studies often fail to include forced migrant or refugees. The goal of this study was to estimate the prevalence of pediatric surgical conditions among refugees in east Africa.MethodsWe used the previously validated Surgeons OverSeas Assessment of Surgical Need (SOSAS) that utilizes cross-sectional design with random cluster sampling to assess prevalence of surgical disease among participants aged 0 to 18 years in Nyarugusu refugee camp, Tanzania. We used descriptive and multivariable analyses including an average marginal effects model.ResultsA total of 1,658 participants were included in the study. The mean age of our sample was 8.3 ± 5.8 years. A total of 841 participants (50.7%) were male and 817 participants (49.3%) were female. A total of 513 (n = 30.9%) reported a history or presence of a problem that may be surgical in nature, and 280 (54.6%) of them reported the problem was ongoing or untreated. Overall, 16.9% had an ongoing problem that may be amenable to surgery. We found that increasing age and recent illness were associated with having a surgical problem on both our multivariable analyses.ConclusionTo our knowledge, this is the first and largest study of prevalence of surgical conditions among refugee children in sub-Saharan Africa. We found that over 16% (one-in-six) of refugee children have a problem that may be amenable to surgery. Our results provide a benchmark upon which other studies in conflict or post-conflict zones with refugee or forced migrant populations may be compared.

Ultrasound-Guided Selective Bronchial Intubation: A Feasibility Study in Pediatric Animal Model.

ObjectiveSelective one-lung ventilation used to optimize neonatal and pediatric surgical conditions is always a demanding task for anesthesiologists, especially during minimally invasive thoracoscopic surgery. This study aims to introduce an ultrasound-guided bronchial intubation and exclusion technique in a pediatric animal model.MethodsSeven rabbits were anesthetized and airway ultrasound acquisitions were done.ResultsTracheal tube progression along the trachea to the right bronchus and positioning of the bronchial blocker in the left bronchus were successfully done with consistent ultrasound identification of relevant anatomical structures.ConclusionThe study provided a new application of ultrasound in airway management. More advanced experimental studies are needed since this technique has the potential for translation to pediatric anesthesia.

Using stated-preferences methods to develop a summary metric to determine successful treatment of children with a surgical condition: a study protocol

IntroductionWide variation in the management of key paediatric surgical conditions in the UK has likely resulted in outcomes for some children being worse than they could be. Consequently, it is...

Social media communities for patients and families affected by congenital pediatric surgical conditions.

BackgroundSocial media has become a means to allow individuals affected by rare diseases to connect with others. This study aimed to characterize the use of three popular social media platforms by individuals affected by common pediatric surgery index conditions.MethodsA systematic search of Instagram, Facebook, and Twitter was performed using standardized terms for the following pediatric surgical conditions: anorectal malformation, biliary atresia, bronchopulmonary sequestration, congenital diaphragmatic hernia (CDH), congenital pulmonary airway malformation, duodenal atresia, esophageal atresia/tracheoesophageal fistula (EA/TEF), gastroschisis, Hirschsprung disease (HD), and omphalocele. Accounts active within the last year were analyzed and assessed.ResultsA total of 666 accounts were identified. Instagram was the most common platform, but accounts dedicated to support and story sharing were most common on Facebook. Biliary atresia and CDH had the largest communities identified. Support groups were most common among those dedicated to EA/TEF (43.3%, p < 0.001). Most accounts were created by parents, but accounts dedicated to HD had the greatest proportion founded by patients (22.4%, p = 0.04).ConclusionsSocial media use is common among patients and families affected by congenital surgical conditions. Certain diseases have larger communities and support networks. Knowledge about their existence may allow surgeons to direct patients towards supportive communities and resources.Level of evidenceIV.