Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Summary Background Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. Methods We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung’s disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. Findings We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung’s disease) from 264 hospitals (89 in high-income countries, 166 in middleincome countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in lowincome countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. Interpretation Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between lowincome, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030

Various Surgical Techniques of Lesional vas Deferens Repair in Rat Experiments

Various surgical techniques for the repair of injured vas deferens in rat experiment Introduction: The herniotomy for inguinal hernia is one of the most frequent surgical procedures in paediatric surgery. The incidence of complication following primary inguinal herniotomy in neonates is not rare and repair of the injured vas deferens (VD) is not standardized. The aim of this experimental study was to assess the contusion of VD during the surgery with a surgical instrument and to perform and consequently analyze some possibilities of a simple repair method under the control of operating loupe. Methods: Seventy male rats were divided into seven subgroups according to the type of the vas deferens injury and its repair consequently: 1. Contusion, 2. cut-off and a simple one layer vasovasostomy sewn by absorbable sewing material, 3. cut-off and joining by an intraluminally lead fibre of absorbable sewing material knotted externally, 4. = 3. using non- absorbable sewing material, 5. = 2. combine with intraluminally situated absorbable sewing fibre fixed externally,6. = 5. combine with intraluminally situated non-absorbable sewing fibre fixed externally, 7. = 5. without external fixation. Fibres of non-absorbable sewing material were removed 3 weeks after the first operation. Operated or injured parts of..

Various Surgical Techniques of Lesional vas Deferens Repair in Rat Experiments

Various surgical techniques for the repair of injured vas deferens in rat experiment Introduction: The herniotomy for inguinal hernia is one of the most frequent surgical procedures in paediatric surgery. The incidence of complication following primary inguinal herniotomy in neonates is not rare and repair of the injured vas deferens (VD) is not standardized. The aim of this experimental study was to assess the contusion of VD during the surgery with a surgical instrument and to perform and consequently analyze some possibilities of a simple repair method under the control of operating loupe. Methods: Seventy male rats were divided into seven subgroups according to the type of the vas deferens injury and its repair consequently: 1. Contusion, 2. cut-off and a simple one layer vasovasostomy sewn by absorbable sewing material, 3. cut-off and joining by an intraluminally lead fibre of absorbable sewing material knotted externally, 4. = 3. using non- absorbable sewing material, 5. = 2. combine with intraluminally situated absorbable sewing fibre fixed externally,6. = 5. combine with intraluminally situated non-absorbable sewing fibre fixed externally, 7. = 5. without external fixation. Fibres of non-absorbable sewing material were removed 3 weeks after the first operation. Operated or injured parts of..

Various Surgical Techniques of Lesional vas Deferens Repair in Rat Experiments

Souhrn Úvod: Plastika tříselné kýly patří k nejčastějším operačním výkonům dětské chirurgie. Výskyt komplikací, které mohou po těchto operacích následovat, není zanedbatelný. Možnosti léčby a postupy ošetření poraněných struktur tříselného kanálu, zejména chámovodu, nejsou v dětském věku dosud standardizovány. Cílem této experimentální práce bylo posoudit vliv zhmoždění chámovodu v průběhu operace chirurgickým nástrojem. Druhým úkolem studie bylo porovnání jednotlivých metod ošetření poraněného chámovodu a vytvoření algoritmu jeho ošetření v podmínkách standardních pracovišť dětské chirurgie bez možnosti použití operačního mikroskopu, jen s použitím lupových brýlí. Metodika: Do experimentální studie bylo zařazeno 70 potkanů - samců, kteří byli rozděleni do sedmi skupin podle arteficiálního typu poranění chámovodu a jeho následného ošetření: 1. zhmoždění chámovodu, 2. přetětí chámovodu a anastomóza jeho konců pomocí jednotlivých stehů vstřebatelným šicím materiálem, 3. přetětí chámovodu a spojení jeho konců pomocí intraluminálně zavedeného vlákna vstřebatelného šicího materiálu uzleného na zevní straně stěny chámovodu, 4. = 3. s použitím nevstřebatelného šicího materiálu, 5. = 2. doplněná o intraluminálně uložené vlákno vstřebatelného šicího materiálu fixovaného na zevní straně stěny chámovodu, 6. = 5. s...Various surgical techniques for the repair of injured vas deferens in rat experiment Introduction: The herniotomy for inguinal hernia is one of the most frequent surgical procedures in paediatric surgery. The incidence of complication following primary inguinal herniotomy in neonates is not rare and repair of the injured vas deferens (VD) is not standardized. The aim of this experimental study was to assess the contusion of VD during the surgery with a surgical instrument and to perform and consequently analyze some possibilities of a simple repair method under the control of operating loupe. Methods: Seventy male rats were divided into seven subgroups according to the type of the vas deferens injury and its repair consequently: 1. Contusion, 2. cut-off and a simple one layer vasovasostomy sewn by absorbable sewing material, 3. cut-off and joining by an intraluminally lead fibre of absorbable sewing material knotted externally, 4. = 3. using non- absorbable sewing material, 5. = 2. combine with intraluminally situated absorbable sewing fibre fixed externally,6. = 5. combine with intraluminally situated non-absorbable sewing fibre fixed externally, 7. = 5. without external fixation. Fibres of non-absorbable sewing material were removed 3 weeks after the first operation. Operated or injured parts of...Katedra chirurgieAcademic Department of SurgeryLékařská fakulta v Hradci KrálovéFaculty of Medicine in Hradec Králov