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

Perianal abscess and fistula-in-ano in children – evaluation of treatment efficacy. Is it possible to avoid recurrence?

Introduction: Perianal abscess and fistula-in-ano are common findings in infants and children. The perianal abscess is usually a manifestation of a fistula-in-ano. Experience of our center indicates general lack of knowledge of the origin of the abscess and therefore, it is usually treated by incision and drainage, which leads to repeated recurrences. Aim: We aimed to present the optimal management of fistula-in-ano and perianal abscess in order to reduce or even eliminate the risk of recurrence. Material and methods: The retrospective study included 24 infants with perianal abscess treated at our center between 2013 and 2015. Patients were divided into two groups: group I (50%) was primary treated in our center, while group II had undergone prior surgical interventions in other hospitals. Fistula-in-ano was intraoperatively identified in all patients (100%) and fistulotomy was performed. Results: No fecal incontinence or recurrence of perianal abscess were observed in any of our patients. In group II, the disorder was associated with severe inflammation, some patients underwent an additional surgical intervention, such as incision and drainage of an extensive buttock’s abscess; patients required longer antibiotic therapy and prolonged hospitalization. Conclusion: Minimally invasive approach (sitz baths, antibiotic therapy, puncture or incision and drainage of the abscess) appears tempting due to its simplicity and lack of need for general anesthesia, but it is associated with a high recurrence rate. Fistulotomy and fistulectomy, which are slightly more invasive procedures, significantly reduce the recurrence rate of fistulain- ano and perianal abscess

Ropnie i przetoki odbytu u dzieci – ocena skuteczności leczenia. Czy można uniknąć nawrotów?

Wprowadzenie: Ropnie i przetoki odbytu są częstym schorzeniem w populacji dziecięcej. U większości pacjentów ropień odbytu stanowi manifestację obecności przetoki odbytu. Doświadczenia naszego ośrodka wskazują na powszechny brak wiedzy w tym zakresie i postępowanie ograniczone wyłącznie do nacięcia ropnia, co w większości przypadków prowadzi do wielokrotnych wznów. Cel: Celem pracy jest przedstawienie możliwych sposobów postępowania oraz ocena ich skuteczności w wyeliminowaniu nawrotów ropni i przetok odbytu. Materiał i metoda: Przeanalizowano retrospektywnie dokumentację medyczną 24 niemowląt leczonych z powodu ropni i przetok odbytu w naszym ośrodku w latach 2013–2015. Połowa pacjentów (grupa I) była pierwotnie leczona w naszym ośrodku, druga połowa (grupa II) przed przyjęciem miała wykonywane interwencje chirurgiczne w innych ośrodkach. U wszystkich pacjentów z ropniami odbytu śródoperacyjnie zidentyfikowano kanał przetoki odbytu (100%) i wykonano fistulotomię. Wyniki: U żadnego pacjenta nie obserwowano nawrotu ropnia odbytu ani nietrzymania stolca. U pacjentów z grupy II obserwowano bardziej nasilony stan zapalny. Część z nich wymagała również dodatkowych procedur chirurgicznych w postaci drenażu rozległego ropnia pośladka; wymagali oni również dłuższej antybiotykoterapii i hospitalizacji. Wnioski: Procedury małoinwazyjne (nasiadówki, antybiotykoterapia, nakłucie lub nacięcie i drenaż ropnia) są kuszące z uwagi na swoją prostotę i brak konieczności znieczulenia pacjenta, ale wiążą się z powikłaniami i dużą liczbą nawrotów. Stosowanie procedur bardziej inwazyjnych (fistulotomia, fistulektomia) wiąże się z koniecznością znieczulenia pacjenta i leczenia operacyjnego, ale pozwala znacznie zredukować częstość nawrotów i innych powikłań