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

Non-operative Management of Adhesive Intestinal Obstruction in Children over a 12 year period at Waikato Hospital

Title: Non-Operative Management of Adhesive Intestinal Bowel Obstruction in Children over a 12year Period at Waikato HospitalIntroduction: Post-operative small bowel adhesions causing bowel obstruction is common in adults but is uncommon in the paediatric age group. The incidence of adhesive intestinal obstruction (AIO) requiring surgical intervention ranges between 2-8% in paediatric patients and majority would occur within the first 2 years after surgery.&#x0D; Aim: To review our experience at a tertiary centre in children under 15years who were admitted with adhesive intestinal obstruction over a 12 year time period and to compare this with other international reports&#x0D; Methodology: This retrospective case series study of all paediatric surgical patients (aged between 1-15 years) admitted with adhesive intestinal obstruction to Waikato Hospital over a 12 year time period were identified by ICD-10-AM codes. Their demographic variables, information of previous surgery and the admissions details including particulars of management were tabulated.&#x0D; Results: Out of 66 admissions, 10 were excluded and 56 admissions were analysed. 35 patients were successfully managed non-operatively and 21 patients proceeded for operative management (7 early and 14 late). Of the operative group, 3 underwent bowel resections (2 early and 1 late). There was no statistically significant difference between length of stay (LOS) among patients with non-operative and operative management. There was also no statistically significant difference between LOS among patients with early (≤24 hours) operative management and late (&gt;24 hours) operative management. In assessing secondary aims, statistically significant differences in the time of presentation from initial surgery was noted for patients who underwent appendectomy who trended towards earlier presentation compared to other laparotomies.&#x0D; Conclusion: This study demonstrated that there could still be a role of non-operative management of children with adhesive bowel obstruction but decision on further management should be clearly defined within 24hours to prevent development of complications.</jats:p

Comparison of suture ligation and clip application for the treatment of patent ductus arteriosus in preterm neonates

ObjectiveWe reviewed the experience of 2 centers performing surgical ligation of patent ductus arteriosus in preterm neonates to identify whether the choice of surgical technique—suture ligation or clip application—affected outcome.MethodsBetween 2000 and 2005, 67 newborn infants had open surgical closure of patent ductus arteriosus: 33 by suture ligation and 34 by clip application. The groups were similar in age and sex.ResultsThe average length of the procedure was 55.8 ± 13.7 minutes for suture ligation and 30.8 ± 8.7 minutes for clip application (P < .05). Six neonates had intraoperative bleeding in the suture ligation group. Four patients had significant postoperative complications in the suture ligation group, compared with 2 in the clip application group.ConclusionsThis study demonstrates that clip application results in a significant reduction in the operative time and, possibly, in less morbidity