Abstract Purpose Neonatal mortality from gastroschisis in sub-Saharan Africa is high, while in high – income countries, mortality is less than 5%. The purpose of this study was to describe the ...maternal and neonatal characteristics of gastroschisis in Uganda, estimate the mortality and elucidate opportunities for intervention. Methods An ethics-approved, prospective cohort study was conducted over a one-year period. All babies presenting with gastroschisis in Mulago Hospital in Kampala, Uganda were enrolled and followed up to 30 days. Univariate and descriptive statistical analysis was performed on demographic, maternal, perinatal, and clinical outcome data. Results 42 babies with gastroschisis presented during the study period. Mortality was 98% (n = 41). Maternal characteristics demonstrate a mean maternal age of 21.8 (± 3.9) years, 40% (n = 15) primiparous, and fewer than 10% (n = 4) of mothers reported a history of alcohol use, and all denied cigarette smoking and NSAID use. Despite 93% (n = 39) of mothers receiving prenatal care and 24% (n = 10) a prenatal ultrasound, correct prenatal diagnosis was 2% (n = 1). Perinatal data show that 81% of deliveries occurred in a health facility. The majority of babies (58%) arrived at Mulago Hospital within 12 h of birth, however 52% were breastfeeding, 53% did not have intravenous access and only 19% had adequate bowel protection in place. Four patients (9%) arrived with gangrenous bowel. One patient, the only survivor, had primary closure. Average time to death was 4.8 days, range < 1 to 14 days. Conclusion The mortality of gastroschisis in Uganda is alarmingly high. Improving prenatal diagnosis and postnatal care of babies in a tertiary center may improve outcome.
Purpose
Intestinal obstruction caused by intestinal atresia is a surgical emergency in newborns. Outcomes for the jejunal ileal atresia (JIA), the most common subtype of atresia in low-income ...countries (LIC), are poor. We sought to assess the impact of utilizing the Bishop–Koop (BK) approach to JIA in improving outcomes.
Methods
A retrospective cohort study was performed on children with complex JIA (Type 2–4) treated at our national referral hospital from 1/2018 to 12/2022. BK was regularly used starting 1/1/2021, and outcomes between 1/2021 and 12/2022 were compared to those between 1/2018 and 12/2020. Statistical significance was set at
p
< 0.05.
Results
A total of 122 neonates presented with JIA in 1/2018–12/2022, 83 of whom were treated for complex JIA. A significant decrease (
p
= 0.03) was noted in patient mortality in 2021 and 2022 (
n
= 33, 45.5% mortality) compared to 2018–2020 (
n
= 35, 71.4% mortality). This translated to a risk reduction of 0.64 (95% CI 0.41–0.98) with the increased use of BK.
Conclusion
Increased use of BK anastomoses with early enteral nutrition and decreased use of primary anastomosis improves outcomes for neonates with severe JIA in LIC settings. Implementing this surgical approach in LICs may help address the disparities in outcomes for children with JIA.
Background
A popular paradigm to support surgical education for low- and middle-income countries (LMICs) is partnering with high-income country (HIC) surgeons. These relationships may, however, be ...asymmetric and fail to optimally address the most pressing curricular needs. We explored the effectiveness of our LMIC-HIC educational partnership.
Methods
Through a partnership between a HIC (Canada) and a LMIC (Uganda), three candidate surgeons were commissioned for a custom designed 1-year training experience at our HIC accredited pediatric surgical training centre as part of their overall formal education. The training curriculum was developed in collaboration with the LMIC pediatric surgeon and utilized competency-based medical education principles. A Likert and short-answer survey tool was administered to these trainees upon completion of their training.
Results
All prescribed milestones as well as specialty certification by examination of the College of Surgeons of East, Central and Southern Africa was achieved by participating fellows, each of whom have begun clinical practice, leadership and teaching roles in their home country. Although several obstacles were identified by fellows, all agreed that the experience boosted their clinical and teaching abilities, and was worth the effort.
Conclusion
This endeavour in global pediatric surgical training represents a significant innovation in surgical education partnerships and would be reproducible across different surgical subspecialties and contexts. Such collaborative efforts represent a feasible upskilling opportunity towards addressing global surgical service capacity.
Level of evidence
V.
Background
Neonatal bowel perforations pose a significant disease burden for pediatric surgeons around the world. However, very little is known about these perforations in low-income settings. This ...study aims to investigate the epidemiology of neonatal perforations at a tertiary hospital in Uganda.
Results
Twenty neonates with bowel perforation who were admitted to a single national referral hospital from May 2020 to April 2021 were included. Fifty-five percent (
n
= 11) of the neonates in this cohort were male, and 16 were term with birth weight above 2.5 kg. Thirteen were below 1 week of age and all maternal ages were less than 40 years. Pneumoperitoneum was the most common finding on erect abdominal X-ray and colon was the frequent site of perforation. Forty percent of the babies in this cohort had blood group O+. Fifty-five percent of our patients died before discharge.
Conclusion
Outcomes for neonatal bowel perforations are still dismal. Health workers taking care of neonates should have a high index of suspicion for neonatal gastrointestinal perforations.
IntroductionAs childhood mortality from infectious diseases falls across sub-Saharan Africa (SSA), the burden of disease attributed to surgical conditions is increasing. However, limited data exist ...on paediatric surgical outcomes in SSA. We compared the outcomes of five common paediatric surgical conditions in SSA with published benchmark data from high-income countries (HICs).MethodsA multicentre, international, prospective cohort study was undertaken in hospitals providing paediatric surgical care across SSA. Data were collected on consecutive children (birth to 16 years), presenting with gastroschisis, anorectal malformation, intussusception, appendicitis or inguinal hernia, over a minimum of 1 month, between October 2016 and April 2017. Participating hospitals completed a survey on their resources available for paediatric surgery.The primary outcome was all-cause in-hospital mortality. Mortality in SSA was compared with published benchmark mortality in HICs using χ2 analysis. Generalised linear mixed models were used to identify patient-level and hospital-level factors affecting mortality. A p<0.05 was deemed significant.Results1407 children from 51 hospitals in 19 countries across SSA were studied: 111 with gastroschisis, 188 anorectal malformation, 225 intussusception, 250 appendicitis and 633 inguinal hernia. Mortality was significantly higher in SSA compared with HICs for all conditions: gastroschisis (75.5% vs 2.0%), anorectal malformation (11.2% vs 2.9%), intussusception (9.4% vs 0.2%), appendicitis (0.4% vs 0.0%) and inguinal hernia (0.2% vs 0.0%), respectively. Mortality was 41.9% (112/267) among neonates, 5.0% (20/403) in infants and 1.0% (7/720) in children. Paediatric surgical condition, higher American Society of Anesthesiologists score at primary intervention, and needing/receiving a blood transfusion were significantly associated with mortality on multivariable analysis.ConclusionMortality from common paediatric surgical conditions is unacceptably high in SSA compared with HICs, particularly for neonates. Interventions to reduce mortality should focus on improving resuscitation and timely transfer at the district level, and preoperative resuscitation and perioperative care at paediatric surgical centres.
In many resource-limited settings, patients with Hirschsprung’s Disease (HD) undergo initial diverting colostomy, followed by pull-through, and finally, colostomy closure. This approach allows for ...decompression of dilated and thickened bowel and improved patient nutritional status. However, this three-stage approach prolongs treatment duration, with significant stoma morbidity, costs, and impact on quality of life. Our aim was to determine whether pull-through for HD can safely be performed with simultaneous stoma closure, reducing treatment approach from three to two stages.
Children with HD and diverting colostomy were prospectively followed as they underwent pull-through with simultaneous stoma closure. Their in-hospital course and 3-mo outpatient course were assessed for postoperative complications. Patients with total colonic HD, redo pull-through, and residual dilated colon were excluded from the study.
Of the 20 children, 17 were male (n = 17, 85%). All patients had rectosigmoid HD. The median weight, age at colostomy formation, and age at pull-through were 11.05 kg (interquartile range IQR 10-12.75), 0.9 y (IQR 0.25-2.8), and 2.08 y (IQR 1.28-2.75), respectively. Mean duration with colostomy before pull-through was 1.1 y (standard deviation 1.51). Median hospital length of stay was 6 d (IQR 5-7). Early complications included anastomotic leak (n = 1), perianal skin excoriation (n = 2), surgical site skin infection (n = 3), and fascial dehiscence (n = 1). Longer-term complications included stricture (n = 1, 5%) and enterocolitis (n = 2, 10%).
In this small case series, we have demonstrated that pull-through with simultaneous stoma closure can be safely performed in resource-constrained settings. Further studies are needed to understand the quality of life and economic impact of this change in management for HD patients.
Gastroschisis causes near complete mortality in low-income countries (LICs). This study seeks to understand the impact of bedside bowel reduction and silo placement, and protocolized resuscitation on ...gastroschisis outcomes in LICs.
We conducted a retrospective cohort study of gastroschisis patients at a tertiary referral center in Kampala, Uganda. Multiple approaches for bedside application of bowel coverage devices and delayed closure were used: sutured urine bags (2017–2018), improvised silos using wound protectors (2020–2021), and spring-loaded silos (2022). Total parental nutrition (TPN) was not available; however, with the use of improvised silos, a protocol was implemented to include protocolized resuscitation and early enteral feeding. Risk ratios (RR) for mortality were calculated in comparison to historic controls from 2014.
368 patients were included: 42 historic controls, 7 primary closures, 81 sutured urine bags, 133 improvised silos and 105 spring-loaded silos. No differences were found in sex (p = 0.31), days to presentation (p = 0.84), and distance traveled to the tertiary hospital (p = 0.16). Following the introduction of bowel coverage methods, the proportion of infants that survived to discharge increased from 2% to 16–29%. In comparison to historic controls, the risk of mortality significantly decreased: sutured urine bags 0.65 (95%CI: 0.52–0.80), improvised silo 0.76 (0.66–0.87), and spring-loaded silo 0.65 (0.56–0.76).
Bedside application of bowel coverage and protocolization decreases the risk of death for infants with gastroschisis, even in the absence of TPN. Further efforts to expand supply of low-cost silos in LICs would significantly decrease the mortality associated with gastroschisis in this setting.
Treatment Study.
III (Retrospective Comparative Study).
Background
1.7 billion of the world’s 2.2 billion children do not have access to surgical care. COVID-19 acutely exacerbated this problem; delaying or preventing presentation and access to surgical ...care globally. We sought to quantify the effect of COVID-19 on children requiring surgery in Uganda.
Methods
Average monthly incident, elective pediatric surgical patient volume was calculated by sampling clinic logs before and during the pandemic, and case volume was quantified by reviewing operative logbooks for all surgeries in 2020 at Mulago Hospital, Kampala. Disability-Adjusted Life Years (DALYs) resulting from untreated disease were calculated and used to estimate economic impact using three different models.
Results
Expected elective pediatric surgery cases were 956. In 2020, pediatric surgery at Mulago was limited to 46 elective cases, approximately 5% of the expected incident cases, leading to a backlog of 910 patients and a loss of 10,620.12 DALYs. The economic impact of more than 10,000 disability years in Uganda is conservatively estimated at $23 million USD with other measures estimating ~ $120 million USD.
Conclusion
The COVID-19 pandemic limited access to pediatric surgery in Uganda, making a chronic problem acutely worse, with costly consequences for the children and health system.
Background
Recommendations by the Lancet Commission on Global Surgery regarding surgical care in low- and middle-income countries (LMICs) require development to address the needs of children. The ...Global Initiative for Children’s Surgery (GICS) was founded in 2016 to identify solutions to problems in children’s surgery by utilizing the expertise of practitioners from around the world. This report details this unique process and underlying principles.
Methods
Three global meetings convened providers of surgical services for children. Through working group meetings, participants reviewed the status of global children’s surgery to develop priorities and identify necessary resources for implementation. Working groups were formed under LMIC leadership to address specific priorities. By creating networking opportunities, GICS has promoted the development of LMIC-LMIC and HIC-LMIC partnerships.
Results
GICS members identified priorities for children’s surgical care within four pillars: infrastructure, service delivery, training and research. Guidelines for provision of care at every healthcare level based on these pillars were created. Seventeen subspecialty, LMIC chaired working groups developed the Optimal Resources for Children’s Surgery (OReCS) document. The guidelines are stratified by subspecialty and level of health care: primary health center, first-, second- and third-level hospitals, and the national children’s hospital. The OReCS document delineates the personnel, equipment, facilities, procedures, training, research and quality improvement components at all levels of care.
Conclusion
Worldwide collaboration with leadership by providers from LMICs holds the promise of improving children’s surgical care. GICS will continue to evolve in order to achieve the vision of safe, affordable, timely surgical care for all children.
Background
Gastroschisis mortality in sub-Saharan Africa (SSA) remains high at 59–100%. Silo inaccessibility contributes to this disparity. Standard of care (SOC) silos cost $240, while median ...monthly incomes in SSA are < $200. Our multidisciplinary American and Ugandan team designed and bench-tested a low-cost (LC) silo that costs < $2 and is constructed from locally available materials. Here we describe in vivo LC silo testing.
Methods
A piglet gastroschisis model was achieved by eviscerating intestines through a midline incision. Eight piglets were randomized to LC or SOC silos. Bowel was placed into the LC or SOC silo, maintained for 1-h, and reduced. Procedure times for placement, intestinal reduction, and silo removal were recorded. Tissue injury of the abdominal wall and intestine was assessed. Bacterial and fungal growth on silos was also compared.
Results
There were no gross injuries to abdominal wall or intestine in either group or difference in minor bleeding. Times for silo application, bowel reduction, and silo removal between groups were not statistically or clinically different, indicating similar ease of use. Microbiologic analysis revealed growth on all samples, but density was below the standard peritoneal inoculum of 10
5
CFU/g for both silos. There was no significant difference in bacterial or fungal growth between LC and SOC silos.
Conclusion
LC silos designed for manufacturing and clinical use in SSA demonstrated similar ease of use, absence of tissue injury, and acceptable microbiology profile, similar to SOC silos. The findings will allow our team to proceed with a pilot study in Uganda.
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