Introduction:Parenteral nutrition (PN) is a life-saving intervention for neonates with gastroschisis. As most low and middle-income countries lack access to comprehensive neonatal PN, we evaluated the feasibility and safety of a pragmatic intravenous nutrition strategy for neonates with gastroschisis in sub-Saharan Africa. Methods:Local protocols for partial parenteral nutritional support and early enteral feeding were developed across the seven pediatric surgery centers participating in the Gastroschisis Interventional Study (n=192). Protocols aimed to provide up to 100 kcal/kg/day using 10% dextrose as maintenance fluid, with amino acid preparations and lipid emulsions added when locally available. Trophic breastmilk was commenced on admission, with enteral feeds advanced from the day following defect closure. Results:In the postintervention phase (n=127), all centers administered 10% dextrose as maintenance fluid. Six centers provided parenteral amino acid, and two centers additionally provided parenteral lipid. The proportion of neonates receiving parenteral nutritional support with 10% dextrose and amino acids increased from 18.5% to 66.1% between the pre- and postintervention phases. The median duration of parenteral nutritional support among survivors was 14 days (interquartile range (IQR): 9-22 days). Intravenous nutritional support was mainly administered by peripheral venous access, with no major clinical complications observed. Conclusions:Partial neonatal intravenous nutritional support using locally available products was feasible and safe across study centers. This approach represents a pragmatic interim strategy in settings where neonatal PN is unavailable. Expanding access to neonatal PN remains essential to achieving Sustainable Development Goal 3.2 to end preventable neonatal deaths by 2030.

AIMS:Simulation training enhances efficacy and safety of preformed silo deployment in gastroschisis. Limitations of existing simulation models include use of biological material, low fidelity, poor durability, and high cost. We developed a novel gastroschisis simulation model and report its validation and performance in a multicentre interventional study. METHOD:Paediatric surgeons collaborated with a medical-model specialist to develop a novel GAstroschisis BaBY (GABBY)-T model. This was validated against two existing simulation models by 15 paediatric surgeons using a Likert scale (1-10) to compare each model (A,B,C) to real-life application, including tactile feedback, realism, and usefulness. Data are presented as median (range). Sixteen GABBY-T models were used to teach preformed silo use as part of a Gastroschisis Interventional Study in 37 hospitals across sub-Saharan Africa. Durability of the models was recorded. RESULTS:GABBY-T model features non-biological silicone bowel, improved fidelity, and ability to simulate all aspects of preformed silo use for gastroschisis care, at $390/model. Usefulness, realism, tactile feedback (p < 0.01) and overall experience (p < 0.05) were all rated significantly higher in the new model compared to the other models (A = 9, 8, 8, 9), (B = 6, 5, 6.5, 5), (C = 6, 5.5, 5, 6), respectively. 33 % of surgeon participants would recommend older models while 100 % recommended the new model for training. During the Gastroschisis Interventional Study, each model was used >100 times. 5/16 models sustained minor bowel tears without affecting performance. Four models suffered damage requiring replacement components. CONCLUSIONS:The GABBY-T model for preformed silo application simulation outperforms previous models. GABBY-T model has high fidelity and durability at moderate cost, facilitating training of large numbers of healthcare providers.

First referral hospitals, often known as district hospitals, are neglected in the discourse on universal health coverage in low-income and middle-income countries (LMICs). However, these hospitals are important for delivering safe surgery for 313 million people. This study aims to understand the structures, processes and outcomes of patients undergoing surgery in these centres in LMICs. This is a preplanned secondary analysis using data from two high-quality randomised controlled trials undergoing major abdominal surgery across six LMICs. Type of hospital was the main explanatory variable, defined according to the WHO taxonomy as first referral (ie, district or rural) and referral (ie, secondary or tertiary). Of the included 15 657 patients across 80 hospitals from 6 countries, 3562 patients underwent surgery in first referral and 12 149 patients underwent surgery in referral centres. First referral centres have lower full-time surgeons (median: 1 vs 20, p<0.001) and medically trained anaesthetists (28.6% vs 87.1%, p<0.001) compared with referral centres. Patients undergoing surgery in first referral centres were more likely to have lower rates of American Society of Anaesthesiologist (ASA) grades III-V (8.1% vs 22.7%, p<0.001), but higher rates of emergency procedures (65.1% vs 56.6%, p<0.001). In first referral centres, there was a significantly higher use of WHO surgical safety checklist (99.4% vs 93.3%, p<0.001) compared with referral centres. In adjusted analyses, there were no differences in 30-day mortality (OR 1.09, 95% CI 0.73 to 1.62) and surgical site infection (OR 1.30, 95% CI 0.89 to 1.90) between first referral and referral centres. Postoperative mortality and surgical site infection remain similar between first referral and referral centres in LMICs. There may be a clear need to upscale surgical volume safely in first referral centres to meet global surgical needs. High-quality research is needed to drive safe expansion of surgical workforce and strengthen referral pathways within these surgical health systems in LMICs.

BACKGROUND:In our communities there are large numbers of longstanding external hernias that remain untreated. This paper describes the epidemiological characteristics of these hernias. The data is expected to provide guidelines for sustained national and international efforts to reduce the burden of hernia by performing large-scale elective hernia repairs.METHOD:Between January 1998 and December 2007, a simple pro-forma was designed and used to record, in a prospective manner, the age, sex of patient and anatomical site of all external hernias seen and operated on both as emergencies and non-emergencies. These were patients who presented to a single general and paediatric surgeon at the Komfo Anokye Teaching Hospital in Kumasi, Ghana.RESULTS:A total of 2,506 patients were studied, of which 1,930 were male and 576 female, giving a male:female ratio of 3.4:1. Inguinal hernia was seen in 1,766 patients: 1,613 males and 153 females, a male:female ratio of 10.5:1. Children 4 years old or younger accounted for 20.9% of inguinal hernias. Femoral hernia was seen in 79 patients: 70 females and 9 males. These groin hernias were diagnosed in 1,845 patients, accounting for 73.6% of all patients. Incisional hernia was diagnosed in 380 patients (15.2%): 179 males and 201 females-a male:female ratio of 1:1.1. These two hernia types (groin and incisional) were seen in 2,225 patients, representing 88.8% of all the patients studied. All other hernias studied, including para-umbilical, umbilical and epigastric, were seen in 281 patients, representing 11.2% of the hernias studied.CONCLUSION:The epidemiology of external hernias seen and treated in our hospital is no different from that of hernias in other communities. Sustained efforts at elective repair will reduce the vast numbers of untreated accumulated hernias in our communities and thus prevent unnecessary morbidity and mortality.

BACKGROUND Acute abdominal conditions are a common reason for emergency admission of children. Little is available in the literature about such conditions in our subregion, especially Ghana. OBJECTIVE The aim of this study was to investigate the range of emergency abdominal surgical conditions amongst children in the subregion, with particular reference to Komfo Anokye Teaching Hospital, Kumasi, Ghana. A prospective survey of all children older than 1 year undergoing an emergency abdominal surgery was carried out. METHODS Details of all children (except infants) operated for an acute surgical abdominal condition over a 5-year period were entered into a specially designed form, capturing patient characteristics, surgical causes of the emergency, operative procedure, complications, morbidity and mortality rates. RESULTS Nine hundred fifty-five children aged > 1 year but < 15 years were enrolled in the study. The mean age was 8.8 +/- 3.2 years. The leading causes of surgical abdominal emergencies were typhoid perforation (TP) of the gastrointestinal tract (GIT), 68%; acute appendicitis, 16%; abdominal trauma and intestinal obstruction (including intussusception), 4.7% each; irreducible external hernias, 2.5%; primary peritonitis, 1.0%; gallbladder disease and gastric perforation, 0.8% each. Many children died from the TP group; case fatality for TP alone was 12.6%. The overall mortality was 9.7%. Morbidity was influenced by the presence of major peritoneal contamination, continuing peritonitis and surgical site infections (SSIs), which led to long hospital stay. CONCLUSIONS In our hospital, TP of the GIT, acute appendicitis, intestinal obstruction, irreducible external hernias and primary peritonitis were the most common abdominal emergencies encountered in children after infancy. The high morbidity and mortality in TP is attributable to ignorance, poor sanitation and delay in reporting to hospital for treatment.

Purpose: To study the clinical presentation and analyze the intraoperative findings of children who had surgery for a suspected perforation of the gastrointestinal tract (GIT) following a one to two weeks of a febrile illness, diagnosed as enteric fever.Materials & Methods: Six hundred and fifty children, below 15 years, had surgery in our institution over five years; for a suspected perforation of the GIT following a febrile illness suspected to be typhoid fever. The clinical presentation, diagnosis, intraoperative findings and operative management, postoperative complications, morbidity and mortality were entered into a specially designed proforma and analysed using Epi Info Version 6.02.Results: The male to female ratio was 1.3:1. Clinically, all children had a febrile illness lasting from few days to two weeks, before developing abdominal pains and abdominal tenderness. Sixty-six percent (66%) had gas under the diaphragm on a chest radiograph. Most children were malnourished, dehydrated, anaemic (55% had haemoglobin levels less than 10 g/dl), septicaemic, and with electrolyte imbalance (30% had low potassium values and 50% with low sodium values). During laparotomy, an average of 455.1 +/- 378.5 ml of various types of fluid (from serous to faeculent) was drained from the peritoneal cavity. Over 94% of the patients had a gut perforation during exploratory laparotomy; with a 6.0% negative laparotomies. The perforations were of various sizes (mean diameter 0.8 +/- 0.7 cm) and found on the stomach, terminal ileum, caecum, ascending colon and rectum. Most patients had one perforation, typically oval in shape, on the antimesenteric border of the long axis of the ileum and, at an average distance of 23 +/- 15 cm from the ileocaecal junction. Surgery involved closure of the perforations in 87.9% of patients, resection of a segment of the terminal ileum including the perforations and/or imminent perforations and end-to-end anastomosis in 7.7% of cases, and right hemicolectomy in 2.6%. Postoperative complications occurred in 266 patients and included: surgical site infection (73.3%), incisional hernias (3.4%), reperforation of the terminal ileum (3.0%) anastomotic breakdown (2.3%) enterocutaneous fistulas (1.9%) and postoperative intestinal obstruction (1.9%). Postoperative morbidity and mortality was 30% and 12.6% respectively.Conclusion: The diagnosis of a perforated GIT after a febrile illness (considered to be typhoid fever) leading to acute peritonitis is mainly clinical in our subregion. The management involves aggressive resuscitation of the child and early surgery. Complications are many and varied and taken together with severity of the disease lead to a high morbidity and mortality.

OBJECTIVE:To evaluate the role of pneumatic reduction in the management of intussusception in children in the setting of a sub-Saharan African nation.DESIGN:Prospective case series.SETTING:Tertiary care teaching hospital in Kumasi, Ghana.SUBJECTS:Forty four children, aged 4 months to 13 years, 28 boys and 16 girls, were admitted with a clinical diagnosis of intussusception and confirmed by ultrasonography.INTERVENTIONS:Twenty two children had air enema reduction of the intussusception attempted in the operation theatre under general anaesthesia. The average pressure used for air enema reduction of the intussusceptions was 110.4 mm Hg.MAIN OUTCOME MEASURES:Success of pneumatic reduction, morbidity and mortality.RESULTS:Overall air enema reduction of intussusception was successful in 59.1% of children who underwent this procedure. There were no deaths among children who had a successful air enema reduction of intussusception. One child (11.1%) out of nine who had laparotomy done after a failed pneumatic reduction died. The average length of hospital stay was shorter in those with successful air enema reduction (3.8 +/- 2.3 days, 95% Confidence Interval [CI] = 2.4 to 5.2) than those who had a laparotomy performed for manual reduction of the intussusception after a failed pneumatic reduction (6.7 +/- 5.1 days, 95% CI = 33 to 9.9).CONCLUSION:Although the sample size is small, pneumatic reduction of intussusception in children without peritonitis is possible, practical, and reliable and must be tried first, preferably under general anaesthesia in our sub-region before proceeding to laparotomy in case of failure.