MyPaedSurg: a review of burden and short-term outcome of congenital gastrointestinal surgical conditions in Malaysia

Many congenital anomalies involving gastrointestinal tract which were once considered fatal are now surgically correctable due to advances in perioperative care. However, scarce data are available on outcomes of paediatric surgical care in our setting. Aim: To analyse the burden and short-term outcome of key indicator congenital gastrointestinal anomalies across different regions in Malaysia. Methods: Using the reference study protocol by the Global PaedSurg study group, we conducted a multicentre, 30-day prospective cohort study for children presenting for the first time with any of these conditions i.e. oesophageal atresia (OA), congenital diaphragmatic hernia (CDH), intestinal atresia, gastroschisis, exomphalos, anorectal malformation (ARM) and Hirschsprung’s disease during a consecutive six-months period between October 2021 until April 2022. All 14 public hospitals in Malaysia with specialist paediatric surgery services as of October 2021 were involved and analysed according to regions: the Northern, Central, East Coast and South of Peninsular Malaysia and East Malaysia. Results: 228 patients with 242 study conditions were included in the final analysis. Data were obtained from 14 paediatric surgery centres from 11 states with variable level of experience of the paediatric surgeons. 31.5% of patients contributed by the central region of Malaysia. Antenatal diagnosis were made in 20.6% of patients. 16.2% of patients presented with sepsis while 11.4% and 7.0% presented with hypovolemia and hypothermia respectively. Interventions were carried out in 91.7% of patients. We reported an overall mortality rate of 8.3% with the largest proportion contributed by patients with CDH. Respiratory failure is the leading cause of death with overall rate of 42.9% from all mortalities. Interestingly, no mortality was reported from the East Malaysia i.e. Sabah and Sarawak. Conclusion: Our result showed that overall mortality rate in Malaysia is lower than reported by the Global PaedSurg group for middle income countries at 20.4% while morbidity rate varies

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

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

Testicular atrophy: A complication of non-mumps orchitis after scrotal exploration for presumed testicular torsion

An acute illness related to the scrotum is a common paediatric surgical emergency. Difficulty in ruling out testicular torsion means that scrotal exploration is often performed for other scrotal pathologies, including orchitis. The clinical course of orchitis is usually benign and long-term sequelae are rare. We describe two adolescent boys, previously vaccinated for mumps, whom had scrotal exploration for presumed testicular torsion. Both were found intraoperatively to have orchitis, and both subsequently developed testicular atrophy, within 2 months post-surgery. These cases demonstrate the rare, but potentially devastating, complication of testicular atrophy that may arise in non-mumps orchitis. The causative pathophysiology may involve some degree of testicular compartment syndrome and subsequent ischaemia. Patients must be made aware of the potential for this outcome and be advised on testicular self-examination after surgery

A pilot study comparing parent and adolescent online health information seeking behaviours in elective pediatric surgical situations

Purpose: Little is known of how children seek health information. This study evaluates online health information (OHI) seeking behaviours in adolescents undergoing major elective surgical procedures and compares responses within parent–child dyads. Methods: With institutional approval, we prospectively surveyed parents of children admitted to our institution for major elective operations between November 2017 and November 2018, using convenience sampling. Patients aged 12 years and above were also invited. Each respondent completed an anonymized modification of a previously published survey on Internet usage. Chi squared tests were used for categorical data, with significance at P value < 0.05. Results: Ninety-one parents and 19 patients (median age 15 years, range 12–18) responded, with 13 parent–child pairs. Daily Internet access was reported by 84 (93%) parents and 18 (95%) children, but OHI was sought in 77% of parents and 74% of children. Six (32%) children could not name their admitting condition, compared to 10 (11%) parents. Nine (50%) children consulted family and friends for information compared to 27 (30%) parents. Parents were more likely to access hospital websites (n = 15, 44%) compared to no children (p = 0.01), while most children (n = 7, 70%) accessed non-health websites (e.g. Wikipedia). In the 13 parent–child pairs, only one parent accurately assessed what their child understood of their condition. Most patients (63.6%) did not understand the aspects of their condition that their parents deemed important. Conclusions: This study highlights the differences in parental and child behaviours. Children are equally important to include when counselling. Surgeons can guide both parties to reliable Internet sources for health information. © 2019, Springer-Verlag GmbH Germany, part of Springer Nature

Parental experiences while waiting for children undergoing surgery in Singapore

Abstract Purpose: To explore the experiences and needs of parents while waiting for their children undergoing surgery. Designs and methods: A descriptive qualitative study was conducted. A purposive sample of 11 parents who went through their first waiting experiences during their children‘s surgeries in a Singapore public hospital was recruited. Children younger than or equal to 16 years of age were included. A semi-structured interview guide facilitated the individual face-to-face interviews. Thematic analysis was used. Results: Four themes were identified: “Care and care provision affecting waiting experiences”, “Parental concerns and surgery affecting waiting experiences”, “Coping strategies used during waiting periods” and “Recommendations to improve waiting experiences”. Pre-operative instructions, the professionalism of medical teams, and a lack of timely updates affected parental experiences. Parents expressed their worries. The complexities and types of surgery influenced how they felt. Their concerns included potential complications, surgical outcomes, anesthesia-related side effects, and post-operative care including pain. They spent their waiting times eating, resting, using their smart devices, and coping with a support system. Environmental improvements, more updates, and mobile applications were recommended by the participants. Conclusion: For a parent, the wait during his/her child‘s surgery can be unsettling. Our results give insights into parental waiting experiences and needs during their children‘s surgeries. Practice implications: These findings can guide the improvement of the current practise based on our evidence or the implementation of newer technology to provide better waiting experiences for parents during their children‘s surgeries and to enhance the quality of clients‘ experiences in the hospital