Ibukunolu Olufemi Ogundele

Background: The burden of perioperative complications following pediatric surgery in sub-Saharan Africa is high. Assessment of the patterns and determinants of such complications and their relationship to perioperative mortality are important in identifying indicators of poor outcomes. In this study, we aim to define predictors of perioperative mortality at a tertiary hospital in Nigeria. Methods: This was a retrospective review of medical records between January 2014 and December 2023. We included patients aged 15 years and below, who had general pediatric, oncological or urological surgery under general anesthesia. Information extracted included biodata, diagnosis, American Society of Anesthesiology (ASA) classification of physical status, time of death after surgery, cause of death, and duration of surgery. Data were processed using univariate and multivariate statistical analysis. Results: A total of 1621 patients were analyzed. The 30-day perioperative mortality rate was 2.96% (296 per 10 000 patients). Jejuno-ileal atresia, gastrochisis, and bladder exstrophy were associated with the highest mortality rates, well above 50%. Logistic regression identified neonatal age, ASA class greater than II, prolonged surgery, and repeated surgical procedures as significant predictors of mortality. Sepsis and intestinal or anastomotic failure were identified as the most common direct causes of death. Conclusions: Neonatal age, ASA class greater than II and prolonged and repeated surgery are significant predictors of mortality in children’s surgery in our practice. Efforts should be made to combat sepsis and provide physiologic support and intensive care provision to improve outcomes.

Background: The burden of surgical diseases in children and perioperative complications in sub-Saharan Africa remains high. The assessment of the pattern and the determinants of perioperative mortality plays an invaluable role in identifying indicators of poor outcomes in order to improve overall outcomes in children’s surgery, thus necessitating this study. Methods: A retrospective review of medical records of patients aged 15 years and below, who had general pediatric, oncological, and urological surgeries under general anesthesia between January 2014 and December 2023, with complete records up to at least post-surgery or died within 30 days of surgery, was carried out. Information extracted included biodata, diagnosis, ASA classification of physical status, time of death after surgery, cause of death, and duration of surgery. Data were collated and analyzed using univariate and multivariate statistical tools. Results: A total of 1621 patients were analyzed. The 30-day perioperative mortality rate in this study was 2.96% (296 per 10,000 patients); jejuno-ileal atresia, gastrochisis and bladder exstrophy are the conditions associated with the highest mortality rates, well above 50%. Furthermore, logistic regression model identified neonatal age group, ASA class greater than II and repeated surgical procedures as the significant predictors of mortality, while sepsis and intestinal/anastomosis failure were identified as the most common direct cause of death. Conclusion: Neonatal age group, ASA class greater than II, and repeated surgery are the significant predictors of mortality in children’s surgery in our practice. Efforts should be made to combat sepsis and provide physiologic support and intensive care to improve outcomes. Key messages: What is already known about this subject: Perioperative mortality rate in pediatric surgery in sub-Saharan Africa remains high. Only a few studies in the region have attempted to identify predictors of POM in children. What this study adds: This study revealed the real burden of POM in our practice and identified the determinants of poor outcomes Neonatal age group, high ASA classification and repeated surgeries are significant predictors of mortality in this study Jejuno-ileal atresia and gastrochisis are associated with a high case fatality rate. How this study might affect research, practice or policy: Findings from this study provide potential tools to improve outcomes in pediatric surgery in the region.

Patients with similar diagnoses often arrive in clusters, followed by periods lacking such cases. I observed this pattern during internship and continued to do so throughout my training and years as a surgeon. During specific call hours, clusters of ectopic gestations would occur, while obstructed labour dominated another day. Similar phenomena were noted across various clinical rotations, including paediatric surgery, where multiple intussusception cases would present in quick successions. I have termed this pattern the “Noah’s ark phenomenon in medicine (NAPM).” Collaborating with a colleague, we researched to understand the scientific basis for this observation. Seasonal variations, infectious diseases, behavioural and cultural factors, genetics, healthcare policies, geographical factors, and referral systems have been documented to influence the clustering of surgical cases. This phenomenon highlights the importance of recognizing patterns in clinical case presentations. Understanding NAPM can aid timely resource management, improve targeted training opportunities, engender peer support among patients, and inspire further research to uncover underlying causes and optimize clinical practice. It can also solve master surgery scheduling problems. The clustering of surgical conditions implies more volume, and this translates into better outcomes for surgeons and institutions.

Background: Suboptimal neonatal circumcision analgesia causes a significant stress response. There is continued search for more effective analgesia for neonatal circumcision. We aimed to determine whether lidocaine–prilocaine cream (LPC) prior to dorsal penile nerve block (DPNB) offers better analgesia than DPNB alone. Methods: A prospective randomized study of 72 neonates undergoing plastibell circumcision was randomized into two groups of 36 each. Group I received DPNB alone with 4 mg/kg plain lidocaine. Group II had 1 g LPC applied to the phallus 1 hour before DPNB. Serum cortisol levels were measured 30 min preoperatively and 30 min postoperatively. Heart rate (HR) and peripheral arterial oxygen saturation (SpO₂) were noted at 30 min preoperatively, after DPNB injection, after excising the prepuce, and at 30 min thereafter. The primary outcome measure was change in serum cortisol levels, while secondary outcomes were changes in HR and SpO₂. Results: Both groups had increased mean serum cortisol levels, decreased mean SpO₂ and increased mean HR from baseline. The rise in mean serum cortisol level was significantly lower in group II (8.09±4.53 µg/dL) than that in group I (11.42±7.83 µg/dL) (p=0.034). Changes in SpO₂ and HR were significantly less in group II than that in group I patients (p<0.05), except for HR changes at 30 min after excision of the prepuce (p=0.086). Conclusion: These data suggest that neonates who received LPC prior to DPNB experienced significantly less pain from plastibell circumcision than those who had DPNB alone. Trial registration number: PACTR201906554747665.

Introduction The novel coronavirus disease has had significant impact on healthcare globally. Knowledge of this virus is evolving, definitive care is not yet known and mortality is increasing. We assessed its initial impact on paediatric surgical practice in Nigeria, creating a benchmark for recommendations and future reference. Methods Survey of 120 paediatric surgeons from 50 centres to assess sociodemographics and specific domains of impact of COVID-19 on their services and training in Nigeria. Valid responses were represented as categorical data and presented in percentages. Duplicate submissions for centres were excluded by combining and taking the mean of responses from centres with multiple respondents. Results Response rate was 74 (61%). Forty-six (92%) centres had suspended elective surgeries. All centres continued emergency surgeries but volume reduced in March by 31%. Eleven (22%) centres reported 13 suspended elective cases presenting as emergencies in March, accounting for 3% of total emergency surgeries. Twelve (24%) centres adopted new modalities for managing selected surgical conditions: non-operative reduction of intussusception in 1 (2%), antibiotic management of uncomplicated acute appendicitis in 5 (10%) and more conservative management of trauma and replacement of laparoscopic appendectomy with open surgery in 3 (6%), respectively. Low perception of adequacy of personal protective equipment (PPE) was reported in 35 (70%) centres. Forty (80%) centres did not offer telemedicine for patients’ follow-up. Twenty-nine (58%) centres had suspended academic training. Perception of safety to operate was low in 37 (50%) respondents, indifferent in 24% and high in 26%. Conclusion Majority of paediatric surgical centres reported cessation of elective surgeries while continuing emergencies. There was, however, an acute decline in the volume of emergency surgeries. Adequate PPE needs to be provided and preparations towards handling backlog of elective surgeries once the pandemic recedes. Further study is planned to more conclusively understand the full impact of this pandemic on children’s surgery.

Introduction The novel Coronavirus disease has had significant impact on healthcare globally. Knowledge of this virus is evolving, definitive care is not yet known, and mortality is increasing. We assessed its initial impact on paediatric surgical practice in Nigeria, creating a benchmark for recommendations and future reference. Methods Survey of 120 paediatric surgeons from 50 centres to assess socio-demographics and specific domains of impact of COVID-19 on their services and training in Nigeria. Seventy four surgeons adequately responded. Responses have been analysed. Duplicate submissions for centres were excluded by combining and averaging the responses from centres with multiple respondents. Results Forty-six (92%) centres had suspended elective surgeries. All centres continued emergency surgeries but volume reduced in March by 31%. Eleven (22%) centres reported 13 suspended elective cases presenting as emergencies in March, accounting for 3% of total emergency surgeries. Nine (18%) centres adopted new modalities for managing selected surgical conditions: non-operative reduction of intussusception in 1(2%), antibiotic management of uncomplicated acute appendicitis in 5(10%), more conservative management of trauma and replacement of laparoscopic appendectomy with open surgery in 3(6%) respectively. Low perception of adequacy of Personal Protective Equipment (PPE) was reported in 35(70%) centres. Forty (80%) centres did not offer telemedicine for patients follow up. Twenty-nine (58%) centres had suspended academic training. Perception of safety to operate was low in 37(50%) respondents, indifferent in 24% and high in 26%. Conclusion Majority of paediatric surgical centres reported cessation of elective surgeries whilst continuing emergencies. There is however an acute decline in the volume of emergency surgeries. Adequate PPE need to be provided and preparations towards handling backlog of elective surgeries once the pandemic recedes. Further study is planned to more conclusively understand the full impact of this pandemic on children's surgery. Key words pandemic, COVID-19, children's surgery.