Training and practice of pediatric surgery in Africa: past, present, and future.

The evolution and recognition of pediatric surgery as a specialty in Africa can be divided into 4 distinct phases, starting from early 1920s till the present. The pace of development has been quite variable in different parts of Africa. Despite all recent developments, the practice of pediatric surgery in Africa continues to face multiple challenges, including limited facilities, manpower shortages, the large number of sick children, disease patterns specific to the region, late presentation and advanced pathology, lack of pediatric surgeons outside the tertiary hospitals, and inadequate governmental support. Standardization of pediatric surgery training across the continent is advocated. Collaboration with well-established pediatric surgical training centers in Africa and other developed countries is necessary. The problems of delivery of pediatric surgical services need to be addressed urgently, if the African child is to have access to essential pediatric surgical services like his or her counterpart in the high-income parts of the world.

Management of postoperative enterocutaneous fistulae in children: a decade experience in a single centre.

BACKGROUND: Enterocutaneous fistula (ECF) in children poses a lot of management challenges due to sepsis, malnutrition, fluid and electrolyte deficits, which are frequent complications. Knowledge of prognostic factors of postoperative ECF is essential for therapeutic decision-making processes. This study examined the variables that relate to the outcomes of management of ECF in children. PATIENTS AND METHODS: Consecutive children who were managed for postoperative ECF in our unit between 2000 and 2009 were evaluated. Data were analysed for clinical features, management and its outcome. RESULTS: A total of 54 patients were managed for ECF. Majority of the fistulas were due to operation for infective causes, with typhoid intestinal perforation ranking the highest. Overall, spontaneous closure without operative intervention occurred in 29 (53.7%) patients. Twenty-one (38.9%) patients required restorative operations to close their fistulas, which was successful only in 12 (22.2%) patients. There was a strong correlation between high-output fistulas (jejunal location) and surgical closure (P<0.001). Hypoalbuminaemia and jejunal location profoundly resulted in non-spontaneous closure of ECF (P<0.001) and were associated with high morbidity (P<0.001). Thirteen (24.1%) patients died due to hypokalaemia, sepsis and hypoproteinaemia/hypoalbuminaemia. CONCLUSIONS: Majority of the ECF in children closed spontaneously following high-protein and high-carbohydrate nutrition. Hypoalbuminaemia and jejunal location were important prognostic variables resulting in non-spontaneous closure, while hypokalaemia, sepsis and hypoproteinaemia/hypoalbuminaemia were associated with high mortality in children with ECF.

Paediatric admissions and outcome in a general intensive care unit.

BACKGROUND: It is believed that intensive care greatly improves the prognosis for critically ill children and that critically ill children admitted to a dedicated Paediatric Intensive Care Unit (PICU) do better than those admitted to a general intensive care unit (ICU). METHODS: A retrospective study of all paediatric (< 16 years) admissions to our general ICU from January 1994 to December 2007. RESULTS: Out of a total of 1364 admissions, 302 (22.1%) were in the paediatric age group. Their age ranged from a few hours old to 15 years with a mean of 4.9 ± 2.5 years. The male: female ratio was 1.5:1. Postoperative admissions made up 51.7% of the admissions while trauma and burn made up 31.6% of admissions. Medical cases on the other hand constituted 11.6% of admissions. Of the 302 children admitted to the ICU, 193 were transferred from the ICU to other wards or in some cases other hospitals while 109 patients died giving a mortality rate of 36.1%. Mortality was significantly high in post-surgical paediatric patients and in patients with burn and tetanus. The length of stay (LOS) in the ICU ranged from less than one day to 56 days with a mean of 5.5 days. CONCLUSION: We found an increasing rate of paediatric admissions to our general ICU over the years. We also found a high mortality rate among paediatric patients admitted to our ICU. The poor outcome in paediatric patients managed in our ICU appears to be a reflection of the inadequacy of facilities. Better equipping our ICUs and improved man-power development would improve the outcome for our critically ill children. Hospitals in our region should also begin to look into the feasibility of establishing PICUs in order to further improve the standard of critical care for our children.

Paediatric admissions and outcome in a general intensive care unit

Background: It is believed that intensive care greatly improves the prognosis for critically ill children and that critically ill children admitted to a dedicated Paediatric Intensive Care Unit (PICU) do better than those admitted to a general intensive care unit (ICU). Methods: A retrospective study of all paediatric (< 16 years) admissions to our general ICU from January 1994 to December 2007. Results: Out of a total of 1364 admissions, 302 (22.1%) were in the paediatric age group. Their age ranged from a few hours old to 15 years with a mean of 4.9 ± 2.5 years. The male: female ratio was 1.5:1. Postoperative admissions made up 51.7% of the admissions while trauma and burn made up 31.6% of admissions. Medical cases on the other hand constituted 11.6% of admissions. Of the 302 children admitted to the ICU, 193 were transferred from the ICU to other wards or in some cases other hospitals while 109 patients died giving a mortality rate of 36.1%. Mortality was significantly high in post-surgical paediatric patients and in patients with burn and tetanus. The length of stay (LOS) in the ICU ranged from less than one day to 56 days with a mean of 5.5 days. Conclusion: We found an increasing rate of paediatric admissions to our general ICU over the years. We also found a high mortality rate among paediatric patients admitted to our ICU. The poor outcome in paediatric patients managed in our ICU appears to be a reflection of the inadequacy of facilities. Better equipping our ICUs and improved man-power development would improve the outcome for our critically ill children. Hospitals in our region should also begin to look into the feasibility of establishing PICUs in order to further improve the standard of critical care for our children

Colostomy for high anorectal malformation: an evaluation of morbidity and mortality in a developing country.

Colostomy is a life-saving procedure in newborns with high anorectal malformations (ARM). However, the procedure may be attended by complications, particularly in resource limited settings. This is an evaluation of the morbidity and mortality following colostomy for ARM in newborns in two paediatric teaching centres in a developing country. A retrospective review of 61 neonates who had colostomy for high ARM in 4 years is conducted. The babies were categorised into Group A (weight at presentation < 2.5 kg) and Group B (weight at presentation > 2.5 kg). There were 47 boys and 14 girls aged 18 h to 28 days (median 6 days). There were 23 babies in Group A; 18 had colostomy under local anaesthetic (LA), 5 of whom died while 5 had the procedure done under general anaesthetic (GA), 3 of whom died (mortality 8/23, 34.78%). Group B consisted of 38 babies, 18 had colostomy under GA, 3 died, while in 20 the procedure was under LA, 1 of who died (mortality 4/38, 10.5%). The difference in mortality between groups A and B was statistically insignificant (p < 0.056). There were no significant differences in outcome between the two groups when the type of anaesthesia or types of colostomy were considered. Surgical site infection was the most common 12/61, 19.7%. Of the 12 babies that died, 7 were due to overwhelming infections, 4 respiratory insufficiencies and 1 cyanotic heart disease. The overall procedure related mortality was therefore 7 (11.5%). None of the centres had adequate neonatal intensive care services during the period of this report. Morbidity and mortality following colostomy for ARM in newborns is still high in this setting, due largely to infective complications, particularly in babies < 2.5 kg.

Clinical characteristics and outcome of surgical treatment of childhood rhabdomyosarcoma: a 7-year experience.

BACKGROUND: The aim of this study was to describe the outcome and determine the prognostic factors of outcome of childhood rhabdomyosarcoma in a tertiary hospital in a developing country. PATIENTS AND METHODS: This was a retrospective review of the clinical presentation, investigation, intervention, and treatment outcomes of children with rhabdomyosarcoma in our hospital over a 7-year period. Statistical analysis was performed using Chi-square test. RESULTS: A total of 18 patients were identified with two-thirds being males (n = 12) with median age of 7 years. Most of the children were below 10 years of age. Lower limbs tumour predominated (n = 6) followed by the upper limbs and head and neck (n = 4 each). Other sites included perianal/perineal (n = 3) and the orbit (n = 1). Two patients were Intergroup Rhabdomyosarcoma Study (IRS) group I, four group II, five group III, and seven group IV. Lymph node involvement was the commonest site of metastasis. Clinical group and stage was significantly more advanced in patients older than 10 years compared to younger than 10 years (P = 0.010, P = 0.008, respectively). There were 12 patients with alveolar disease while six had embryonal type of rhabdomyosarcoma. Treatment was by combination chemotherapy, and surgical excision which was done primarily in 11, after chemotherapy in four, and after radiotherapy in one. Two had biopsy only. Five patients are alive, two of them without evidence of disease at average follow-up period of 2 years. CONCLUSION: Mortality from rhabdomyosarcoma in our setting is still unacceptably high. Late presentation may be the major contributor to high mortality. A more aggressive multimodality treatment approach may improve the outcome.

Clinical characteristics and outcome of surgical treatment of childhood rhabdomyosarcoma: a 7-year experience

Background: The aim of this study was to describe the outcome and determine the prognostic factors of outcome of childhood rhabdomyosarcoma in a tertiary hospital in a developing country. Patients and Methods: This was a retrospective review of the clinical presentation; investigation; intervention; and treatment outcomes of children with rhabdomyosarcoma in our hospital over a 7-year period. Statistical analysis was performed using Chi-square test. Results: A total of 18 patients were identified with two-thirds being males (n = 12) with median age of 7 years. Most of the children were below 10 years of age. Lower limbs tumour predominated (n = 6) followed by the upper limbs and head and neck (n = 4 each). Other sites included perianal/perineal (n = 3) and the orbit (n = 1). Two patients were Intergroup Rabdomyosarcoma Study (IRS) group I; four group II; five group III; and seven group IV. Lymph node involvement was the commonest site of metastasis. Clinical group and stage was significantly more advanced in patients older than 10 years compared to younger than 10 years (P = 0.010; P = 0.008; respectively). There were 12 patients with alveolar disease while six had embryonal type of rhabdomyosarcoma. Treatment was by combination chemotherapy; and surgical excision which was done primarily in 11; after chemotherapy in four; and after radiotherapy in one. Two had biopsy only. Five patients are alive; two of them without evidence of disease at average follow-up period of 2 years. Conclusion: Mortality from rhadomyosarcoma in our setting is still unacceptably high. Late presentation may be the major contributor to high mortality. A more aggressive multimodality treatment approach may improve the outcome