Seminars in Pediatric Surgery最新文献

Challenges:

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  1.7 billion children are deprived of surgical care due to economic, political and social factors that lead to inequitable healthcare.

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  90% of children live in LMICs where surgical ecosystems are often deficient with regards to children-specific infrastructure and health providers

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  Nearly half the population in LMICs lives in rural areas, however most surgical facilities are concentrated in urban centers with limited access due to poor infrastructure and costly or difficult transportation.

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  The cycle of poverty is difficult to break; it affects a family's ability to attain education and resources which can hinder the identification, understanding and treatment of surgical problems.

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  There is a lack of political will, both on regional and global fronts, to mobilize resources to improve surgical access in general, but particularly for children.

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  Children's surgery must be recognised as an essential component of both childhood and surgical care policies and initiatives.

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  To improve outcomes, the general health of a child must be made a priority. This entails promotion of a safe and healthy environment, good reproductive and antenatal health, along with regular checkups.

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  Local surgical systems must be strengthened by raising awareness, increasing training opportunities and improving infrastructure.

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  Health facilities should be categorized according to resource availability and there should be locally relevant expectations of care at each resource level. Referral systems must be developed to avoid late presentations and mismanagement.

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  Global health funders and political stakeholders must be engaged to raise funds for children's surgery, with a focus on equitable distribution of resources.

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  Population control may be a sustainable long-term solution to correct the disbalance between need and resources, particularly in rapidly growing countries with a poor economic forecast.

The Tanzania-Oxford Children's Surgery Partnership is a longstanding capacity building and research collaboration. Over a 21-year period, this non-hierarchical partnership has worked to develop from service delivery to children surgical system strengthening in Tanzania. This has directly impacted the children's surgery and workforce by increasing the number of pediatric surgeons in the country and upskilling nurses, anesthetists, and pediatricians. Clinical skills acquisition has been complemented by the development of leadership, mentorship, and research acumen. The partnership has also delivered critical upgrading of infrastructure which has significantly increased operative volume and allowed for the provision of minimally invasive children's surgery. A children's research network has been established, with a focus on research equity and local data ownership adhering to local ethics, leading to prolific academic output. At the core of this partnership has been the recognition that achieving sustainable change requires local leadership, long-term commitment, and ‘bottom-up’ change. We described the historical events and steps taken by our partners to achieve the universal provision of children's surgery in Tanzania.

An estimated two-thirds of the world's children and adolescents, most of whom live in low- and middle- income countries lack access to safe, quality, and timely surgical care. While much efforts have been made in the last decade to advocate for children’ surgery, several economic and policy gaps remain, hampering progress and investments. These gaps range from lack of adequate data on costs and cost-effectiveness, high rate of out-of-pocket payments and limited health insurance coverage, to non-inclusion of children's surgical care in public child health policies and surgical plans. Given the magnitude of the limitations, actions and initiatives need to be prioritised to facilitate coordinated investments. Urgent investments are required to generate reliable and convincing data on costs of children's surgical care, as well as costs of equipment and supplies. To support actions and initiatives, children's surgery should be included in any existing and planned child public health initiatives and surgical plans. Integration of injury prevention and early identification of surgical conditions into school health initiatives would also strengthen care. The overall return on investment in children's surgical care are enormous with implications for child survival, family, and society stability as well as country workforce and economy. Investments should be well coordinated at country, regional and global levels to avoid waste of resources and duplication of efforts, while encouraging convergence of efforts.

An unacceptable inequity exists in the burden of pediatric surgical disease and access to surgical and anesthesia care between low- and middle-income countries (LMIC) and high-income countries (HIC). Civil society organizations (CSOs) and the voluntary sector have been integral in addressing this imbalance. This article summarizes the roles that these organizations have played in improving pediatric surgical care globally and how their roles have evolved over the years. CSOs and voluntary organizations have historically provided operations on LMIC patients; however, the focus has shifted to building sustainable surgical systems by training a skilled workforce, improving local infrastructure, and contributing to research and advocacy efforts. See Table 1.

The treatment of congenital anomalies (structural birth defects) is common to all the surgical sub-specialties dealing with children. Globally more than 90 % of all babies born with a congenital anomaly are born in middle-and-low-income countries where there is often limited access to needed surgical care. Challenges include lacks of early identification, registry and surveillance systems, missing referral pathways, shortage of trained surgical expertise and insufficient surgical infrastructure. Poverty, transportation logistics, financial constraints and social stigma are also serious barriers for families. There is, however, growing recognition of the priority to expand services, encouraged by the World Health Organization and other global players, and examples of successful models of care. Registry programs are growing, especially in Latin America. The Ponseti method of clubfoot care has been revolutionary on a global scale. The role of not-for-profit non-governmental-organizations has been instrumental in fundraising, training and logistical support as exemplified in the care of oro-facial clefts. Specialized “niche” hospitals are providing needed sub-specialist expertise. The way forward includes the need for effective partnerships, innovative methods to distribute care out from referral hospitals into the districts and the development of national plans embedded in national health policy.

Lack of access to pediatric medical devices and innovative technology contributes to global disparities in children's surgical care. There are currently many barriers that prevent access to these technologies in low- and middle-income countries (LMICs). Technologies that were designed for the needs of high-income countries (HICs) may not fit the resources available in LMICs. Likewise, obtaining these devices are costly and require supply chain infrastructure. Once these technologies have reached the LMIC, there are many issues with sustainability and maintenance of the devices. Ideally, devices would be created for the needs and resources of LMICs, but there are many obstacles to innovation that are imposed by institutions in both HICs and LMICs. Fortunately, there is a growing interest for development of this space, and there are many examples of current technologies that are paving the way for future innovations. Innovations in simulation-based training with incorporated learner self-assessment are needed to fast-track skills acquisition for both specialist trainees and non-specialist children's surgery providers, to scale up access for the larger population of children. Pediatric laparoscopy and imaging are some of the innovations that could make a major impact in children's surgery worldwide.

There are notable inequities in health outcomes for children based on their social determinants of health (SDOH), including where they are born and live, their primary language, their race and ethnicity, socioeconomic status, and more. These health inequities are not restricted to resource limited settings; here we highlight three broad topics that are relevant to pediatric surgeons in the United States (US): access to care and disparities, and examples of inequities in firearm-related injuries and appendicitis.

Most of our patients will at some point require operative interventions, yet there can be significant challenges in accessing this care and navigating our health systems, particularly around complex perioperative care. There are significant opportunities to improve equitable care by helping patients navigate our health systems and connecting them with additional resources, including screening for primary care services.

Firearm-related injuries are now the leading cause of death in children in the US, with significant associated morbidity for non-fatal injuries. There are notable inequities in the risk of injury and types of injuries experienced by children based on their SDOH. Appendicitis is one of the most common pathologies managed by pediatric surgeons, with similar inequities in the rates of perforated appendicitis based on a child's SDOH.

For both issues, addressing the inequities our patients experience requires moving upstream and working towards prevention. Key opportunities include better research and data to understand the drivers for observed inequities, multidisciplinary collaboration, community engagement, and public health advocacy among others. As a profession, we have a responsibility to work to address the health inequities our patients experience.

Partnerships in Global Surgery have evolved over several decades and continue to do so based on reports from different experiences and collaborations. These should be characterised by their objectives, leadership and “championship,” communication, ethics and equity. Partnerships take the form of academic collaborations or clinical support whose details vary with the different stakeholders involved. Over time, these have evolved based on challenges, successes, and failures. Recently, quality improvement activities have been increasingly initiated with locally derived information. This has come from local databases in low and middle income country (LMIC) settings whose maintenance and analysis have been done through academic collaborations. For many sites in LMICs, there would be very little advance in paediatric surgery without collaborations. Despite this, problems still arise from collaborations due to failure to learn from past problems, lack of local championship, poor communication, and externally driven objectives. For success and longevity, the collaboration must pay attention to unique the needs of the site, champions and equity.

The clinical presentation, diagnosis and management of anorectal malformation has been well described in the literature, however the experience with these conditions in low-and middle-income countries is often shaped in unique ways due to the social, cultural and economic factors at work in these regions. This leads to adaptation of modifications in management options for these babies that usually present as delayed cases with added poor prognostic factors like sepsis leading to need for emergency resuscitation and overall increased morbidity and mortality. This article explores the anomaly from a global surgery lens and outlines the spectrum of the anomaly, burden faced in the resource constrained environment and the management options adopted for successful management under the available circumstances.

The appropriate management of pediatric liver malignancies, primarily hepatoblastoma and hepatocellular carcinoma, requires an in depth understanding of contemporary preoperative risk stratification, experience with advanced hepatobiliary surgery, and a good relationship with one’s local or regional liver transplant center. While chemotherapy regimens have become more effective, operative indications more well-defined, and overall survival improved, the complexity of liver surgery in small children provides ample opportunity for protocol violation, inadequate resection, and iatrogenic morbidity. These guidelines represent the distillation of contemporary literature and expert opinion as a means to provide a framework for preoperative planning and intraoperative decision-making for the pediatric surgeon.