Paediatric surgery in Uganda: current challenges and opportunities

Over half of the Ugandan population is under 18-years-old. Surgical care is provided by district general hospitals, whose activity is coordinated by fourteen regional referral hospitals. Mulago National Referral Hospital in Kampala is the main tertiary centre for paediatric surgery. The paediatric surgical need is vast and unmet, with around 15% of Ugandan children having an untreated surgical condition. Most paediatric surgical procedures are performed for neonatal emergencies and trauma, with widespread task-sharing of anaesthesia services. Facilities face shortages of staff, drugs, theatre equipment, and basic amenities. Surgical treatment is delayed by the combination of delays in seeking care due to factors such as financial constraints, gender inequality and reliance on community healers, delays in reaching care due to long distances, and delays in receiving care due to overcrowding of wards and the sharing of resources with other specialties. Nonetheless, initiatives by the Ugandan paediatric surgical community over the last decade have led to major improvements. These include an increase in capacity thanks to the opening of dedicated paediatric theatres at Mulago and in regional hospitals, the start of a paediatric surgical fellowship at Mulago by the College of Surgeons of East, Central and Southern Africa (COSECSA) and development of surgical camps and courses on management of paediatric surgical emergencies to improve delivery of paediatric surgical care in rural areas

Colonic duplication with recto-urethral fistula: Elusive diagnosis and successful treatment in a resource-limited setting

AbstractA 3-year-old Ugandan boy presented with 18 months of constipation and 12 months of pneumaturia and fecaluria. Physical exam revealed abdominal distension and a palpable mass anterior to the rectum. Previous contrast enema had been non-diagnostic, and a voiding cystourethrogram (VCUG) had confirmed a recto-urethral fistula. After surgical evaluation, a computed tomography (CT) scan suggested colonic duplication, and a laparotomy was performed for rapidly progressive bowel obstruction. A tubular colonic duplication with fecal impaction was found, necessitating fecal disimpaction and a double divided colostomy. Two months later at re-laparotomy, the septum between the duplicated colonic lumens was found to extend proximally to the mid transverse colon and distally to the upper rectum, and was divided. No urethral fistula was identified, and the colostomy was recreated. At a third operation, the colostomy was reversed. The patient is well at one-year follow up, without evidence of recurrent fistula or stricture. This case shows that colonic duplication in children can be an elusive diagnosis. Often, a variety of radiographic studies may be needed and may be difficult to interpret. In cases with colo-urinary fistula, the fistula may respond to fecal diversion without requiring operative repair. Management in a resource-limited setting can still yield positive outcome

Access to pediatric surgery delivered by general surgeons and anesthesia providers in Uganda: Results from 2 rural regional hospitals.

Abstract Background Significant limitations in pediatric surgical capacity exist in low- and middle-income countries, especially in rural regions. Recent global children's surgical guidelines suggest training and support of general surgeons in rural regional hospitals as an effective approach to increasing pediatric surgical capacity. Methods Two years of a prospective clinical database of children's surgery admissions at 2 regional referral hospitals in Uganda were reviewed. Primary outcomes included case volume and clinical outcomes of children at each hospital. Additionally, the disability-adjusted life-years averted by delivery of pediatric surgical services at these hospitals were calculated. Using a value of statistical life calculation, we also estimated the economic benefit of the pediatric surgical care currently being delivered. Results From 2016 to 2019, more than 300 surgical procedures were performed at each hospital per year. The majority of cases were standard general surgery cases including hernia repairs and intussusception as well as procedures for surgical infections and trauma. In-hospital mortality was 2.4% in Soroti and 1% in Lacor. Pediatric surgical capacity at these hospitals resulted in over 12,400 disability-adjusted life-years averted/year. This represents an estimated economic benefit of 10.2 million US dollars/year to the Ugandan society. Conclusion This investigation demonstrates that lifesaving pediatric procedures are safely performed by general surgeons in Uganda. General surgeons who perform pediatric surgery significantly increase surgical access to rural regions of the country and add a large economic benefit to Ugandan society. Overall, the results of the study support increasing pediatric surgical capacity in rural areas of low- and middle-income countries through support and training of general surgeons and anesthesia providers

Pediatric surgery as an essential component of global child health.

Recent initiatives in global health have emphasized universal coverage of essential health services. Surgical conditions play a critical role in child health in resource-poor areas. This article discusses (1) the spectrum of pediatric surgical conditions and their treatment; (2) relevance to recent advances in global surgery; (3) challenges to the prioritization of surgical care within child health, and possible solutions; (4) a case example from a resource-poor area (Uganda) illustrating some of these concepts; and (5) important child health initiatives with which surgical services should be integrated. Pediatric surgery providers must lead the effort to prioritize children\u27s surgery in health systems development

Outcomes and unmet need for neonatal surgery in a resource-limited environment: estimates of global health disparities from Kampala, Uganda.

PURPOSE: Reported outcomes of neonatal surgery in low-income countries (LICs) are poor. We examined epidemiology, outcomes, and met and unmet need of neonatal surgical diseases in Uganda. METHODS: Pediatric general surgical admissions and consults from January 1, 2012, to December 31, 2012, at a national referral center in Uganda were analyzed using a prospective database. Outcomes were compared with high-income countries (HICs), and met and unmet need was estimated using burden of disease metrics (disability-adjusted life years or DALYs). RESULTS: 23% (167/724) of patients were neonates, and 68% of these survived. Median age of presentation was 5days, and 53% underwent surgery. 88% survived postoperatively, while 55% died without surgery (p CONCLUSIONS: More than two thirds of surgical neonates survived despite late presentation and lack of critical care. Epidemiology and outcomes differ greatly with HICs. A high burden of hidden mortality exists, and only a negligible fraction of the population need for neonatal surgery is met by health services

Best Buy in Public Health or Luxury Expense?

ObjectiveTo determine the cost-effectiveness of building and maintaining a dedicated pediatric operating room (OR) in Uganda from the societal perspective.BackgroundDespite the heavy burden of pediatric surgical disease in low-income countries, definitive treatment is limited as surgical infrastructure is inadequate to meet the need, leading to preventable morbidity and mortality in children.MethodsIn this economic model, we used a decision tree template to compare the intervention of a dedicated pediatric OR in Uganda for a year versus the absence of a pediatric OR. Costs were included from the government, charity, and patient perspectives. OR and ward case-log informed epidemiological and patient outcomes data, and measured cost per disability adjusted life year averted and cost per life saved. The incremental cost-effectiveness ratio (ICER) was calculated between the intervention and counterfactual scenario. Costs are reported in 2015 US$and inflated by 5.5$37.25 per disability adjusted life year averted or $3321 per life saved, compared with no existing operating room. The ICER is well below multiple cost-effectiveness thresholds including one times the country's gross domestic product per capita ($694). The ICER remained robust under 1-way and probabilistic sensitivity analyses.ConclusionOur model ICER suggests that the construction and maintenance of a dedicated pediatric operating room in sub-Saharan Africa is very-cost effective if hospital space and personnel pre-exist to staff the facility. This supports infrastructure implementation for surgery in sub-Saharan Africa as a worthwhile investment

Efforts to improve outcomes among neonates with complex intestinal atresia: a single-center low-income country experience.

PURPOSE: Intestinal obstruction caused by intestinal atresia is a surgical emergency in newborns. Outcomes for the jejunal ileal atresia (JIA), the most common subtype of atresia in low-income countries (LIC), are poor. We sought to assess the impact of utilizing the Bishop-Koop (BK) approach to JIA in improving outcomes. METHODS: A retrospective cohort study was performed on children with complex JIA (Type 2-4) treated at our national referral hospital from 1/2018 to 12/2022. BK was regularly used starting 1/1/2021, and outcomes between 1/2021 and 12/2022 were compared to those between 1/2018 and 12/2020. Statistical significance was set at p < 0.05. RESULTS: A total of 122 neonates presented with JIA in 1/2018-12/2022, 83 of whom were treated for complex JIA. A significant decrease (p = 0.03) was noted in patient mortality in 2021 and 2022 (n = 33, 45.5% mortality) compared to 2018-2020 (n = 35, 71.4% mortality). This translated to a risk reduction of 0.64 (95% CI 0.41-0.98) with the increased use of BK. CONCLUSION: Increased use of BK anastomoses with early enteral nutrition and decreased use of primary anastomosis improves outcomes for neonates with severe JIA in LIC settings. Implementing this surgical approach in LICs may help address the disparities in outcomes for children with JIA

Treatment abandonment in children with Wilms tumor at a national referral hospital in Uganda.

INTRODUCTION: The incidence of pediatric Wilms tumor (WT) is high in Africa, though patients abandon treatment after initial diagnosis. We sought to identify factors associated with WT treatment abandonment in Uganda. METHODS: A cohort study of patients < 18 years with WT in a Ugandan national referral hospital examined clinical and treatment outcomes data, comparing children whose families adhered to and abandoned treatment. Abandonment was defined as the inability to complete neoadjuvant chemotherapy and surgery for patients with unilateral WT and definitive chemotherapy for patients with bilateral WT. Patient factors were assessed via bivariate logistic regression. RESULTS: 137 WT patients were included from 2012 to 2017. The mean age was 3.9 years, 71% (n = 98) were stage III or higher. After diagnosis, 86% (n = 118) started neoadjuvant chemotherapy, 59% (n = 82) completed neoadjuvant therapy, and 55% (n = 75) adhered to treatment through surgery. Treatment abandonment was associated with poor chemotherapy response (odds ratio [OR] 4.70, 95% confidence interval [CI] 1.30-17.0) and tumor size > 25 cm (OR 2.67, 95% CI 1.05-6.81). CONCLUSIONS: Children with WT in Uganda frequently abandon care during neoadjuvant therapy, particularly those with large tumors with poor response. Further investigation into the factors that influence treatment abandonment and a deeper understanding of tumor biology are needed to improve treatment adherence of children with WT in Uganda

Unifying Children's Surgery and Anesthesia Stakeholders Across Institutions and Clinical Disciplines: Challenges and Solutions from Uganda

AbstractBackgroundThere is a significant unmet need for children's surgical care in low‐ and middle‐income countries (LMICs). Multidisciplinary collaboration is required to advance the surgical and anesthesia care of children's surgical conditions such as congenital conditions, cancer and injuries. Nonetheless, there are limited examples of this process from LMICs. We describe the development and 3‐year outcomes following a 2015 stakeholders' meeting in Uganda to catalyze multidisciplinary and multi‐institutional collaboration.MethodsThe stakeholders' meeting was a daylong conference held in Kampala with local, regional and international collaborators in attendance. Multiple clinical specialties including surgical subspecialists, pediatric anesthesia, perioperative nursing, pediatric oncology and neonatology were represented. Key thematic areas including infrastructure, training and workforce retention, service delivery, and research and advocacy were addressed, and short‐term objectives were agreed upon. We reported the 3‐year outcomes following the meeting by thematic area.ResultsThe Pediatric Surgical Foundation was developed following the meeting to formalize coordination between institutions. Through international collaborations, operating room capacity has increased. A pediatric general surgery fellowship has expanded at Mulago and Mbarara hospitals supplemented by an international fellowship in multiple disciplines. Coordinated outreach camps have continued to assist with training and service delivery in rural regional hospitals.ConclusionCollaborations between disciplines, both within LMICs and with international partners, are required to advance children's surgery. The unification of stakeholders across clinical disciplines and institutional partnerships can facilitate increased children's surgical capacity. Such a process may prove useful in other LMICs with a wide range of children's surgery stakeholders