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

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 middle-income 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 low-income 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 low-income, 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

Morphological changes on small-bowel fetal allografts in mice

The aim of this study was to evaluate the early morphological development and acute rejection process in fetal intestine allografts. Grafts from C57BL/6 fetal intestines were implanted in an avascular form in BALB/C recipients. A syngeneic group of animals was used to compare the evolution. the allogeneic recipients were distributed in 6 groups, according to the day of sacrifice (3rd, 4th, 5th, 6th, 7th, and 10th postoperational day (POD)) and the control group on the 2nd, 5th, and 7th POD. These grafts were stained with hematoxylin and eosin for histological evaluation, in agreement with the classification of Auber et al. (Chirurgie 123:122-130, 1998). Data showed a progressive development of the graft until POD 5. On POD 3 and 4, a top grade of development and an initial rejection were observed. From POD 5-7 and on POD 10, the acute rejection reaction was more important than the development process. the higher level of rejection was observed on POD 10, and it was similar to the 7th POD. Our results showed good graft development until POD 5. After that, the acute rejection response impeded analysis of the development process. (C) 2003 Wiley-Liss, Inc.Universidade Federal de São Paulo, Escola Paulista Med, Dept Cirurgia, Disciplina Tecn Operatoria & Cirurgia Expt, São Paulo, BrazilUniversidade Federal de São Paulo, Escola Paulista Med, Dept Morphol, Disciplina Histol, São Paulo, BrazilUniversidade Federal de São Paulo, Escola Paulista Med, Dept Cirurgia, Disciplina Tecn Operatoria & Cirurgia Expt, São Paulo, BrazilUniversidade Federal de São Paulo, Escola Paulista Med, Dept Morphol, Disciplina Histol, São Paulo, BrazilWeb of Scienc