Global paediatric surgery: meeting an unmet need-the response of the British Association of Paediatric Surgeons

Aim Outline the response from an organisation regarding the unmet needs in global children’s surgery Method The burden of global surgical disease, whilst daunting, is becoming increasingly better defined as agencies, surgical colleges and professional specialty associations all attempt to increase capacity in terms of manpower, support education and find sustainable solutions to the deficit of health in treating women and children. However, definition of the problem does not in itself create change and similarly, humanitarian activities including volunteering by established surgical practitioners and other non-governmental organisations (NGOs) make only marginal improvement in the standards of care on offer at a global level. Results The International Affairs Committee, British Association of Paediatric Surgeons (BAPS) has had its target firmly set on investing in potential leaders within paediatric surgery in low- and middle-income countries (LMICs), and sharing elements of the educational programme made available for training within the UK and Ireland with the aim of contributing to the solutions of inequity in the surgical standards available to the world’s children. Conclusion This article outlines some of the practical steps that have been deployed by BAPS by way of sharing the responsibility for problem-solving at a global level. It also highlights the need for clarity in advocacy and the route through which effective communication can translate into wider and more effective delivery of surgical care for children

A day in the life of a paediatric surgeon: a PAPSA research study

Objectives This study aimed to create a snapshot picture of the global workload of paediatric surgeons and identify differences between countries.Methods Surgeons from 13 paediatric surgical units in different countries across the world were asked to record the number and type of admissions to the paediatric surgery service over a 24-h period from 8 a.m. on 23 May 2012.Results Data were recorded for 13 units from 13 countries: 11 low and middle  income countries (LMICs) and two high-income countries (HICs). Dar es Salaam, Tanzania, had the greatest number of admissions. Two units in HICs had the lowest number of admissions, other than the Nigerian unit, which only had three admissions due to a hospital strike on the day surveyed. The percentage of emergency  admissions ranged from 38 to 83%. Those units with the highest number of total admissions tended to also have the highest proportion of emergencies. Trauma was  the most frequently reported admission reason, accounting for 18% of admissions. However, there were no cases of trauma in HIC units.Conclusion The spectrum of paediatric surgery differs between countries, in  particular between LMICs and HICs. Units in LMICs tend to have a greater number  of admissions, including a wider variety of conditions and a higher proportion of emergency work. Paediatric surgery in LMICs faces many challenges. This  highlights the importance of training specialist paediatric surgeons in these countries. Further data are still needed to fully outline the burden of disease in paediatric surgery, especially in LMICs.Keywords: epidemiology, global surgery, paediatric surger

Building back better children's surgical services toward universal health coverage: Perspectives from Bangladesh and Zimbabwe

IntroductionThis article is part of the Research Topic ‘Health Systems Recovery in the Context of COVID-19 and Protracted Conflict’. Children's surgical services are crucial, yet underappreciated, for children's health and must be sufficiently addressed to make and sustain progress toward universal health coverage (UHC). Despite their considerable burden and socioeconomic cost, surgical diseases have been relatively neglected in favor of communicable diseases living up to their inauspicious moniker: ‘the neglected stepchild of global health'. This article aims to raise awareness around children's surgical diseases and offers perspectives from two prototypical LMICs on strengthening surgical services in the context of health systems recovery following the COVID-19 experience to make and sustain progress toward UHC.ApproachWe used a focused literature review supplemented by the perspectives of local experts and the 6-components framework for surgical systems planning to present two case studies of Bangladesh and Zimbabwe. The lived experiences of the authors are used to describe the impact of COVID-19 on respective surgical systems and offer perspectives on building back the health system and recovering essential health services for sustainability and resilience.FindingsWe found that limited high-level policy and planning instruments, an overburdened and under-resourced health and allied workforce, underdeveloped surgical infrastructure (from key utilities to essential medical products), lack of locally generated research, and the specter of prohibitively high out-of-pocket costs for children's surgery are common challenges in both countries that have been exacerbated by the COVID-19 pandemic.DiscussionContinued chronic underinvestment and inattention to children's surgical diseases coupled with the devastating effect of the COVID-19 pandemic threaten progress toward key global health objectives. Urgent attention and investment in the context of health systems recovery is needed from policy to practice levels to improve infrastructure; attract, retain and train the surgical and allied health workforce; and improve service delivery access with equity considerations to meet the 2030 Lancet Commission goals, and make and sustain progress toward UHC and the SDGs

Management of undescended testes: a comparative study in England and Africa

Objective The aim of our study was to determine the timing of referrals and the outcome of undescended testes (UDT) over a 4-year period in a tertiary centre in England, and to compare this with a similar centre in Nigeria. Background data Cryptorchidism is a recognized cause of infertility and a key risk factor for testicular malignancy. Current recommendations are that orchidopexy be performed between 12 and 18 months of age; however, there is no consensus on this.Materials and methods Data were obtained for orchidopexies performed between 2003 and 2007 from a tertiary referral centre in England. A standardized proforma was used to collect data into an Excel database, which was analysed and compared with data from a similar centre in Nigeria.Results Eighty-eight patients from a tertiary referral centre in England underwent surgery for UDT. Fifty-six (63.6%) patients were referred and 38 (43.2%) patients were operated on within 2 years of age. Doctors and health visitors accounted for 69 (78.5%) referrals to the tertiary centre. Data from Nigeria demonstrated that of the 61 cases, 13 (21%) patients presented and 11 (18%) patients were operated on by 24 months. Referral beyond 60 months of age in the English series was due to ascending testis, whereas in the Nigerian study, the delayed presentation was due to delayed referral from lack of knowledge of the condition.Conclusion In England and Nigeria, there is a lack of definitive guidelines relating to the appropriate age of referral of patients with UDT. A structured care pathway is needed to enable early detection and definitive management

Fertility preservation service for children and young adults at high risk of infertility; the hub and spoke model

Purpose: To evaluate the evolution of fertility preservation surgery in children and young adults at high risk of infertility from a single centre to a networked ‘Hub and Spoke’ service. Methods: A case note review of patients referred for ovarian or testicular cryopreservation between Jan 2013 and Dec 2023. Demographic data, procurement numbers, and site of procurement were collected. Specialist feedback was obtained to identify the challenges faced. Results: Over time, the number of referrals increased from 4 to 349 patients per year with the number of Spoke centres rising to 36 ovarian and 16 testicular. In 2013–2014; 100% of procurement was ovarian as compared to 2023; 51% ovarian, 49% testicular. Of the 395 referrals in 2021, 81% (n = 319) went on to have procurement and storage of tissue. Between 2013 and 2016, 96% of cases were performed at the Hub. In 2023, 53/349 (15%) cases were performed at the Hub with the remaining 296 (85%) procured at Spoke sites. Surgical issues such as access to theatre, variation and availability of surgical equipment, thermal injury to ovarian tissue and variation in the size of the testicular specimen were identified. Conclusion: The Hub and Spoke model successfully delivers treatment to patients close to home as safely possible within their local treatment centre

Global survey on point-of-care ultrasound (pocus) use in child surgery

Purpose: To undertake a global assessment of existing ultrasound practices, barriers to access, point-of-care ultrasound (POCUS) training pathways, and the perceived clinical utility of POCUS in Child Surgery. Methods: An electronic survey was disseminated via the GICS (Global Initiative of Children’s Surgery) network. 247 anonymized responses from 48 countries were collated. 71.3% (176/247) worked in child surgery. Results: Ultrasound was critical to practice with 84% (147/176) of requesting one daily or multiple times per week. Only 10% (17/176) could access emergency ultrasound < 1 h from request. The main barrier was a lack of trained personnel. HIC surgeons were more likely to have ultrasound training (24/29; 82.8%) compared with LMICs (74/147; 50.3%) (p = .001319; CI 95%). Self-perceived POCUS competence was associated with regularity of POCUS use (p < 0.001; CI 95%). Those who already practice POCUS most commonly use it for trauma, intussusception, and ultrasound-guided procedures. Majority (90%; 159/176) of child surgeons would attend formal POCUS training if available. Conclusions: Ultrasound is critically important in children’s surgery globally, however, many surgeons experience barriers to timely access. There is a strong interest in learning POCUS for relevant pediatric surgical applications. Further research is needed to evaluate the best methods of training, accreditation, and governance

Global Initiative for Children’s Surgery (GICS) Pediatric Trauma Care Initiative: A Call for a Comprehensive Approach to a Global Problem

Introduction: Trauma is a major problem which has a significant health, social, and economic impact. Particularly, pediatric trauma carries substantial mortality and morbidity. This is a great concern for subspecialized general and pediatric surgeons. Therefore, a global initiative for pediatric trauma care is warranted and should be initiated. Aim: The international association “Global Initiative for Children’s Surgery” (GICS) would like to propose and organize a children’s trauma care (CTC) initiative. This initiative should comprehensively address pediatric trauma management globally, especially in low- and middle-income countries (LMICs). The initiative seeks to achieve a structured cooperation and collaboration with respective sister organizations and local stakeholders. Methods: The initiative will address these relevant aspects: 1. first aid; 2. prehospital primary trauma care; 3. hospital primary trauma care; 4. advanced care (ATLS); 5. diagnostic facilities; 6. operation room (OR) equipment; 7. specialized surgical services; 8. rehabilitation; 9. registry, research, and auditing; 10. specialization in pediatric trauma; 11. capacity and confidence building in pediatric trauma; 12. prevention. The GICS CTC provided activities have been recorded and evaluated in a structured manner. This statement paper is based on data of a narrative review as well as expert opinions. Results: The Trauma Working Group of GICS provided specialized trauma prevention leaflets available for translation to different languages. A one-day children’s primary trauma course has been designed to be delivered at the physical GICS meetings. Exercising advocacy, the group addressed several meetings on prevention of pediatric trauma, which included the 75th United Nations General Assembly (UNGA) (2020), GICS IVth meeting in Johannesburg (2020), Norwich (UK) Joint SPRINT Symposium on Pediatric Surgery for Pediatricians (2021), the second online Pan African Pediatric Surgical Association (PAPSA) meeting (2021), the seventh World Congress of the World Federation of Associations of Pediatric Surgeons (WOFAPS) in Prague (2022), and GICS pediatric trauma webinar (2023). Additionally, the working group participated in the preparations of a pediatric trauma module for the World Health Organization (WHO) and published several related studies. The contents of the selected articles added relevant information to the categories stated above. Conclusions: The CTC initiative of GICS is proposed as a mean to address pediatric trauma comprehensively through a process of collaboration and advocacy with existing organizations to achieve awareness, health education, prevention, health, and training. Further, it will support the provision of suitable facilities to health institutions. The establishment of a specialization in pediatric trauma is encouraged. GICS CTC initiative aims to improve pediatric trauma care in LMICs by developing injury prevention strategies; optimizing the use of locally available resources; obtaining commitment by LMICs governments; improvement in all fields of hospital care; improvements in infrastructure, education and training, and attention to data registry and research

Exploratory laparotomy in the management of confirmed necrotizing enterocolitis

Introduction: Necrotizing enterocolitis (NEC) is a serious gastrointestinal emergency in newborn infants. Surgical management includes primary peritoneal drainage and/or exploratory laparotomy with bowel resection. This study describes obstetric complications, postnatal comorbidities, surgical care and intermediate postoperative outcomes in all infants with surgically and/or histologically proven NEC, who underwent exploratory laparotomy at our tertiary referral centre.Materials and methods: We conducted a retrospective review between January 2005 and December 2010. Results are reported as median (range). Fisher’s exact test (two tailed) was used for statistical analysis. A P-value of 0.05 or less was considered statistically significant.Results: A total of 71 infants had suspected (Bell’s stageZ1) NEC. Of them, 32 infants underwent laparotomy for stage 2–3 NEC. We excluded 11 infants with surgically and/or histologically proven spontaneous intestinal perforation. In the remaining 21 infants with confirmed NEC, median gestational age was 27 weeks (23–39 weeks) and median birth weight was 720 g (440–3510 g). NEC was suspected after a median 14 days of life (1–49 days of life). Fifteen patients (71%) were initially managed medically for a median total of 8 days (1–25 days). Laparotomy was performed after a median of 7 days (&lt;1–35 days) from the suspicion of NEC. Eleven infants (52%) underwent bowel resection and enterostomy, four infants (19%) underwent  bowel resection with primary anastomosis and one infant (5%) underwent proximal diverting jejunostomy. Bowel perforation was seen in seven patients (33%). Necrosis totalis was evident in five patients (24%). There were 12 postoperative deaths (57% mortality), and seven deaths (58%) occurred during the first 30 days. Infants who died were more likely to have had absent/reversed enddiastolic flow (n=5, P= 0.64), intrauterine growth retardation (n=5, P = 0.18) or a gestational birth weight between 501 and 750 g (n=9, P = 0.08). In the surviving children (n= 9), the median length of hospital stay was 134 days (87–190 days) and postoperative sequelae were frequently seen.Conclusion: The morbidity and mortality for infants with confirmed NEC who undergo laparotomy remain high in infants despite optimal medical and surgical care. Keywords: exploratory laparotomy, necrotizing enterocolitis, surger

British Association of Paediatric Surgeons International Affairs Committee: A report of international fellowships

Objective This paper describes the fellowship programme of the International Affairs Committee of the British Association of Paediatric Surgeons.Patients and methods The selection of low-income and middle-income country (LMIC) fellows from 2005 to 2016, their funding, experience, and current roles are described. Qualitative and quantitative analysis was performed. Results Thirty-eight trainees from 21 LMIC were awarded fellowships over the 11-year period. Thirty-two have completed the fellowship at time of writing, all are now in consultant positions. Obtaining a visa was the single most cited barrier to starting the fellowship. Twenty completed the questionnaire. Hundred percent felt the  fellowship had contributed to personal development and 71% had altered clinical practice subsequent to their experience. Thirty-three percent have gained research opportunities.Conclusion This evaluation supports LMIC-high-income country partnerships and highlights the benefits of fellowships to both the individual surgeon, their department and patient population.  Keywords: BAPS, fellowship, low- and middle-income country, partnershi

Triorchidism at orchidopexy: a case report

This is an Open Access article distributed under the terms of the Creative Commons Attribution Licens