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Surgical site infections (SSIs) are common and serious complications of surgery. Guidelines on preventing SSIs have been developed, but the role of preoperative bathing with plain soap among paediatric population is unclear. We aimed to assess the effectiveness of pre-operative bathing using plain soap in preventing SSIs among paediatric surgical patients.An open-label, randomised trial was conducted at Muhimbili National Hospital in Tanzania. Preoperatively, patients in the intervention group washed their body using plain soap, while those in the control group did not. The primary outcome was SSI postoperatively. Statistical tests included χ2, Wilcoxon rank sum, and univariate and multivariable logistic regression.Of the 252 patients recruited,114 were randomised to the intervention arm. In the control arm, 40.6% (56/138) of participants developed SSIs compared to 11.4% (13/114) in the intervention arm (p0.01). After adjusting for confounding factors in multivariable analysis, the intervention reduced the odds of an SSI by 80% (OR: 0.20 [95% CI: 0.10, 0.41]; p0.01). Preoperative antibiotics were deemed to be an effect modifier of the association between the intervention and SSI (p = 0.05). The intervention significantly reduced the odds of an SSI by 88% among participants not given preoperative antibiotics (OR: 0.12 [95% CI: 0.05, 0.30]; p0.01).This study has shown that preoperative bathing with soap significantly reduces SSIs in paediatric surgical patients. It is a simple, cost effective and sustainable intervention.Level II.

The aim of this study is to investigate the impact that COVID-19 had on the pattern and trend of surgical volumes, urgency and reason for surgery during the first 6 months of the pandemic in sub-Saharan Africa.This retrospective facility-based study involved collection of paediatric operation data from operating theatre records across 5 hospitals from 3 countries: Zimbabwe, Zambia and Nigeria over the first half of 2019 and 2020 for comparison. Data concerning diagnosis, procedure, anaesthesia, grade, speciality, NCEPOD classification and indication was collected. The respective dates of enactment of cancellation policies in each country were used to compare changes in weekly median surgical case volume before cancellation using the Wilcoxon Sign-Rank Test.A total of 1821 procedures were recorded over the study period. Surgical volumes experienced a precipitous drop overall from a median of 100 cases/week to 50 cases/week coinciding with cancellation of surgical electives. Median accumulated weekly procedures before COVID-related cancellation were significantly different from those after cancellation (p = 0.027). Emergency surgery fell by 23.3% while electives fell by 78,9% (P = 0.042). The most common primary indication for surgery was injury which experienced a 30.5% drop in number of procedures, only exceeded by congenital surgery which dropped 34.7%.The effects of surgical cancellations during the covid-19 pandemic are particularly devastating in African countries where the unmet need and surgical caseload are high. Continued cancellations that have since occurred will cause similar drops in surgical case volume that these health systems may not have the resilience to recover from.Level II.

Introduction: Wilms’ tumour is the most common childhood renal malignancy, with 5–10% of cases presenting bilaterally 1. However, there is currently no consensus between centres on optimal management of bilateral Wilms’ tumours. This is an international multi-centre case series comparing management and outcomes of bilateral Wilms’ tumours between low-income centres (LIC) and high-income centres (HIC). Methods: Patients with bilateral Wilms' tumour were identified from four tertiary referral centres internationally. Data were collected on baseline characteristics, disease status, treatment used and clinical outcomes. Results were compared between individual centres as well as between groups of low-income centres (LIC) and high-income centres (HIC). Results: Data were collected for forty patients. Most patients received preoperative chemotherapy ( n = 38, 95%). The most common surgical procedures were bilateral nephron-sparing surgery ( n = 10, 25%) and nephrectomy with partial nephrectomy ( n = 20, 50%). Ten-year survival after treatment was as follows: LIC's n = 13 (65%); HIC's n = 20 (100%) ( p = 0.01). Discussion: Ten-year survival was significantly higher in HIC's. Our results show this may be caused by patient factors such as later presentation with more advanced disease in low-income centres. This comparative case series is the first to report on a large number of cases from multiple international centres, and to compare key outcomes.

Survival of Wilms tumor (WT) is >90% in high-resource settings but

Background Cancer is a major global health concern and a leading cause of death in paediatric populations worldwide. Malnutrition contributes to a poor prognosis and remains the most common comorbidity leading to death in children with cancer. This retrospective study was developed through Oxford Paediatrics Linking Oncology Research with Electives (OxPLORE)—a medical student-led collaboration of paediatric surgeons and oncologists from low- and middle-income (LMIC) and high-income (HIC) countries. The aim of this study was twofold; firstly, to investigate the nutritional status and outcomes of neuroblastoma paediatric patients in two OxPLORE centres. Secondly, to facilitate the development of research skills of medical students as part of the OxPLORE initiative. Results Nine neuroblastoma patients were identified (YY, n = 4, XX, n = 5) over the study period. Nutritional status was poorer in YY patients (median z-score − 1.57 cf. − 0.7, t = 1.16, p = 0.28), which correlated with poorer survival in the YY cohort (75%), as compared to the XX cohort (100%). YY patients were older at presentation than the XX cohort (57 cf. 13 months, t = 1.959 p = 0.09). Further, tumour presentation was at a later stage in the YY group (75% stage IV). Conclusion This collaboration has shown a correlation in disparities in nutritional status and outcome of neuroblastoma in paediatric populations in YY and XX. These findings can inform institutional quality improvement. Further, this pilot study has highlighted the potential for medical students to undertake international research collaborations.

About 1.7 billion children and adolescents, mostly in low- and middle-income countries (LMICs) lack access to surgical care. While some of these countries have developed surgical plans and others are in the process of developing theirs, children's surgery has not received the much-needed specific emphasis and focus in these plans. With the significant burden of children's surgical conditions especially in low- and middle-income countries, universal health coverage and the United Nations' (UN) Sustainable Development Goals (SDG) will not be achieved without deliberate efforts to scale up access to children's surgical care. Inclusion of children's surgery in National Surgical Obstetric and Anaesthesia Plans (NSOAPs) can be done using the Global Initiative for Children's Surgery (GICS)-modified Children's Surgical Assessment Tool (CSAT) tool for baseline assessment and the Optimal Resources for Children Surgical Care (OReCS) as a foundational tool for implementation.

Objective We aim to compare conventional 3-port with single-incision laparoscopic surgery (SILS) for oophorectomy in patients undergoing ovarian cryopreservation. Background Demand for cryopreservation of ovarian tissue prior to the initiation of gonadotoxic treatment has risen significantly since its introduction in England in 2013. Traditionally, laparoscopic oophorectomy is performed using a 3-port technique with an umbilical port and 2 smaller 5-mm working ports. Energy devices can be used to allow haemostatic dissection of the ovary and this is delivered through the umbilical port site. In an attempt to improve efficiency, post-operative outcomes, and enhance cosmesis; our department initiated the use of the Applied Medical GelPoint Mini Advanced Access Platform single port technique using a vertical trans-umbilical approach for ovarian cryopreservation. Methods All patients undergoing laparoscopic oophorectomy for cryopreservation between September 2013 and August 2017 were included. The patients were consented for SILS, 3-port and open oophorectomies. All patients received maximum local anaesthetic wound infiltration intra-operatively. Case notes and theatre electronic data were reviewed and data was collected on additional procedure, conversion rate, operative time, post-operative analgesia requirement, complications and length of hospital stay. Results A total of 106 patients underwent laparoscopic oophorectomy during the study period. Of these, 40 underwent conventional 3-port, 65 had SILS and 1 patient had open. No cases were converted from the intended method. There was a statistically significant difference in the mean operative time; with SILS being faster than the conventional 3-port method (SILS: 40.4 min; 3-port: 51.7 min; p = 0.017). There was no difference in length of stay or perioperative analgesics, and complication rates in both groups were low. Informal qualitative feedback included surgeons stating that the ovary was much easier to deliver using the SILS technique. Patients were also happy with a single cosmetically appeasing scar hidden within the umbilicus. Conclusion SILS is an acceptable technique in ovarian cryopreservation allowing a quicker operative time, easier delivery of the ovary, and better cosmesis. A learning curve is recognised due to the ergonomics of single port laparoscopy; however, the technique can be established easily in departments with existing laparoscopic capabilities. This is the first paper which establishes this within a Paediatric Surgical setting, and adult literature suggests that further prospective trials may prove some benefit in ovarian tissue volume or time to initiation of treatment due to enhanced recovery.

The Pan African Paediatric Surgery Association (PAPSA) was formed in 1994. The need for an organisation in Africa to voice children’s surgery and the trials and tribulations in forming this organisation was covered in this journal 2 years ago (Heinz R, Kyambi J, Lakhoo K. Surg Int 34(5):499–504, 2018). This article covers the history of the organisation post inception in 1994 to date. The near disbanding of the organisation due to political unrest and wars in Africa, to its success in the recent decade is highlighted in this manuscript.

Purpose: To investigate the relationship between timing of re-introduction of feeds following surgery for Necrotising Enterocolitis (NEC) and important early outcomes.Methods: Secondary analysis of prospectively collected data from paediatric surgical units in UK/Ireland of infants who underwent laparotomy for NEC between 01/03/2013 and 28/02/2014. Multivariable logistic regression analysis was used to compare the relationship of early (≤ 7 days) and later (8-27 days) re-introduction of feeding after surgery on death or need for PN at 28 days, correcting for known cofounders.Results: 41/143 infants (29%) received early and 102/143 infants (71%) had delayed reintroduction of feeding. Infants in the early feeding group had a higher gestational age at birth, higher proportion of growth restriction, lower inotrope requirement, and weremore likely to have undergone primary anastomosis. Following adjustment there was no statistically significant difference detected in the rate of death or need for PN at 28 days, adjusted OR 0.4 (95% CI 0.2-1.1), noting the limited statistical power of this comparison.Conclusions: There is no evidence from this study to support a minimum period of 7 days nil by mouth post laparotomy for infants with NEC. Early feed reintroduction following laparotomy for NEC is safe in appropriate cases.Level of evidence: Level II - Treatment Study Group; Prospective comparative study.Keywords: Bowel rest; Necrotising enterocolitis (NEC); Neonatal; Total parenteral nutrition (TPN); Treatment.

Summary Prevalence of anaemia is high among children in low-income and middle-income countries. Anaemia is an important factor to consider preoperatively as low haemoglobin concentrations can have a negative effect on surgical outcomes and can also lead to surgeries being cancelled or postponed, which can have adverse health implications and stretch already limited resources in these countries. Additionally, blood transfusions to correct anaemia exposes children to safety issues. Therefore, where anaemia is known to be prevalent and resources are scarce, a contextually appropriate and relatively safe minimum haemoglobin concentration for proceeding to surgery could substantially improve patient management and efficiency of the health system. In this Review, we consider why paediatric anaemia is a major public health issue in low-income and middle-income countries, the value of preoperative testing of anaemia, and methods of optimising haemoglobin concentrations in the context of paediatric surgeries taking place in resource-limited settings.

This article describes the Global Surgery Symposium held within the 65th British Association of Paediatric Surgeons (BAPS) Annual Congress in 2018. Global surgery is a rapidly expanding and developing field and is of particular importance in paediatrics since children account for up to 50% of the population in low- and middle-income countries (LMICs). It is estimated that up to a third of childhood deaths in LMICs are the result of a surgical condition, and congenital anomalies have risen to become the 5th leading cause of death in children less than 5-years of age globally. Trainees in high-income countries (HICs) are increasingly interested in global surgery engagement through clinical placements, research, or education, or a combination of these. There is considerable controversy regarding the ethics, practicalities, usefulness, safety, and sustainability of these initiatives. In addition, there is debate as to whether such placements should occur within the paediatric surgery training pathway. Level of evidence 5 (Expert Opinion).

Purpose We aimed to understand the challenges facing children’s surgical care providers globally and realistic interventions to mitigate the catastrophic impact of COVID-19 on children’s surgery. Methods Two online Action Planning Forums (APFs) were organized by the Global Initiative for Children’s Surgery (GICS) with a geographically diverse panel representing four children’s surgical, anesthesia, and nursing subspecialties. Qualitative analysis was performed to identify codes, themes, and subthemes. Results The most frequently reported challenges were delayed access to care for children; fear among the public and patients; unavailability of appropriate personal protective equipment (PPE); diversion of resources toward COVID-19 care; and interruption in student and trainee hands-on education. To address these challenges, panelists recommended human resource and funding support to minimize backlog; setting up international, multi-center studies for systematic data collection specifically for children; providing online educational opportunities for trainees and students in the form of large and small group discussions; developing best practice guidelines; and, most importantly, adapting solutions to local needs. Conclusion Identification of key challenges and interventions to mitigate the impact of the COVID-19 pandemic on global children’s surgery via an objective, targeted needs assessment serves as an essential first step. Key interventions in these areas are underway.

Summary Background Increasing numbers of neonates are undergoing painful procedures in low-income and middle-income countries, with adequate analgesia seldom used. In collaboration with a multi-disciplinary team in Kenya, we aimed to establish the first evidence-based guidelines for the management of routine procedure-related neonatal pain that consider low-resource hospital settings. Methods We did a systematic review by searching MEDLINE, Embase, CINAHL, and CENTRAL databases for studies published from Jan 1, 1953, to March 31, 2019. We included data from randomised controlled trials using heart rate, oxygen saturation (SpO2), premature infant pain profile (PIPP) score, neonatal infant pain scale (NIPS) score, neonatal facial coding system score, and douleur aigue du nouveau-ne scale score as pain outcome measures. We excluded studies in which neonates were undergoing circumcision or were intubated, studies from which data were unextractable, or when pain was scored by non-trained individuals. We did a narrative synthesis of all studies, and meta-analysis when data were available from multiple studies comparing the same analgesics and controls and using the same outcome measures. 17 Kenyan health-care professionals formed our clinical guideline development panel, and we used the Grading of Recommendations, Assessment, Development and Evaluation framework and the panel's knowledge of the local health-care context to guide the guideline development process. This study is registered with PROSPERO, CRD42019126620. Findings Of 2782 studies assessed for eligibility, data from 149 (5%) were analysed, with 80 (3%) of these further contributing to our meta-analysis. We found a high level of certainty for the superiority of breastfeeding over placebo or no intervention (standardised mean differences [SMDs] were −1·40 [95% CI −1·96 to −0·84] in PIPP score and −2·20 [–2·91 to −1·48] in NIPS score), and the superiority of oral sugar solutions over placebo or no intervention (SMDs were −0·38 [–0·61 to −0·16] in heart rate and 0·23 [0·04 to 0·42] in SpO2). We found a moderate level of certainty for the superiority for expressed breastmilk over placebo or no intervention (SMDs were −0·46 [95% CI −0·87 to −0·05] in heart rate and 0·48 [0·20 to 0·75] in SpO2). Therefore, the panel recommended that breastfeeding should be given as first-line analgesic treatment, initiated at least 2 min pre-procedure. Given contextual factors, for neonates who are unable to breastfeed, 1–2 mL of expressed breastmilk should be given as first-line analgesic, or 1–2 mL of oral sugar (≥10% concentration) as second-line analgesic. The panel also recommended parental presence during procedures with adjunctive provision of skin-to-skin care, or non-nutritive sucking when possible. Interpretation We have generated Kenya's first neonatal analgesic guidelines for routine procedures, which have been adopted by the Kenyan Ministry of Health, and have shown a framework for clinical guideline development that is applicable to other low-income and middle-income health-care settings. Funding Wellcome Trust Research Programme, and the Africa-Oxford Initiative.

Political change in the 1990s in Southern Africa influenced the long awaited formation of a children’s surgical association in Africa. Here, within is the historical account of the formation of the Pan African Association of Paediatric Surgeons (PAPSA). The basis of the argument for the formation of PAPSA was that paediatric surgeons from Africa have a wealth of experience and special knowledge of diseases affecting children in the African continent which differ substantially from those encountered in other regions of the world. This historical account is mainly from documentation by 2 of the organisations founding members. Electronic supplementary material The online version of this article (10.1007/s00383-018-4248-y) contains supplementary material, which is available to authorized users.

ObjectiveThe objective was to describe outcomes and investigate factors affecting prognosis at 1 year post intervention for infants with surgical necrotising enterocolitis (NEC).DesignUsing the British Association of Paediatric Surgeons Congenital Anomalies Surveillance System, we conducted a prospective, multicentre cohort study of every infant reported to require surgical intervention for NEC in the UK and Ireland between 1 March 2013 and 28 February 2014. Association of independent variables with 1-year mortality was investigated using multivariable logistic regression analysis.SettingAll 28 paediatric surgical centres in the UK and Ireland.PatientsInfants were eligible for inclusion if they were diagnosed with NEC and deemed to require surgical intervention, regardless of whether that intervention was delivered.OutcomesPrimary outcome was mortality within 1 year of the decision to intervene surgically.Results236 infants were included in the study. 208 (88%) infants had 1-year follow-up. 59 of the 203 infants with known survival status (29%, 95% CI 23% to 36%) died within 1 year of the decision to intervene surgically. Following adjustment, key factors associated with reduced 1-year mortality included older gestational age at birth (adjusted OR (aOR) 0.87, 95% CI 0.78 to 0.96). Being small for gestational age (SGA) (aOR 3.6, 95% CI 1.4 to 9.5) and requiring parenteral nutrition at 28 days post-decision to intervene surgically (aOR 3.5, 95% CI 1.1 to 11.03) were associated with increased 1-year mortality.ConclusionsParents of infants undergoing surgery for NEC should be counselled that there is approximately a 1:3 risk of death in the first post-operative year but that the risk is lower for infants who are of greater gestational age at birth, who are not SGA and who do not require parenteral nutrition at 28 days post-intervention.

Aim No consensus exists about the optimal surgical technique for esophageal replacement. This study reports the surgical outcomes for the gastric pull-up and the colonic interposition procedures. Materials and Methods A retrospective review of children undergoing esophageal replacement surgery between January 2001 and June 2015 across four different pediatric surgery centers was conducted. Data collected included indications, epidemiology, surgical technique, complications, and outcomes. Patients were divided into group A, those that had a gastric pull-up procedure and group B, those that had a colonic interposition procedure. Results In total, 50 patients were included; 29 in group A and 21 in group B. Indications included esophageal atresia, caustic ingestion, and infective esophageal stricture. The median age at the time of surgery was 13 months. The mean length of follow-up was 5.2 years. Three patients died giving a mortality rate of 6%; 2 in group A and 1 in group B.In both groups, early postoperative complications included infective complications, such as wound infections, sepsis, and pneumonia (11), anastomotic leak (7), and respiratory complications (7). Late complications included adhesive bowel obstruction (2), anastomotic strictures (4), redundancy (1), and jejunostomy problems (1). Septic complications and anastomotic strictures occurred more frequently in group B. Further surgery was needed in eight patients; this was significantly higher in group B. Full oral feeding was achieved within 6 months in 91.5%. Conclusion The gastric pull-up and colonic interposition have comparable mortality and outcomes. The colonic interposition was associated with a higher rate of early septic complications, anastomotic strictures, and need for further surgery.

Stoma formation is a common paediatric surgical procedure and yet, there is no low-cost stoma model for technical skills training. We describe a low-cost low-fidelity simulator for stoma formation made from simple easily available materials using porcine bowel and skin. The model was introduced at a regional training day for paediatric surgical registrars. All the trainees rated it as excellent and life-like. We describe an inexpensive stoma model for simulation-based training in technical skills especially in low-middle-income countries (LMICs) due to the cost benefit.

This article outlines the global surgery activities held at the 66th Annual International Meeting of the British Association of Paediatric Surgeons (BAPS) in 2019. For the first time BAPS introduced a plenary session on global surgery. Topics that were covered include management of birth defects in Low-Middle Income Countries (LMIC), mostly gastroschisis, and community-based involvement in children's surgery, knowing that 2.5 billion children worldwide do not have access to surgical care. The presentation on financial burden for families with children needing surgical care highlighted the route to poverty in the absence of governmental support. The Hugh Greenwood lecture covered the involvement of a global organisation, namely Global Initiative for Children's Surgery (GICS) advocating and working towards children's surgery, as this was ignored at the Lancet Commission held in 2015. LEVEL OF EVIDENCE: Level V.

A previously well fifteen-month-old female infant presented to a district general hospital in the United Kingdom with a three-month history of virilisation developing facial acne, coarse pubic hair, labia majora hypertrophy, menstruation, and clitoral enlargement. A functional adrenal tumour was suspected, supported by raised androgen metabolites on urinary steroid profile. An abdominal ultrasound scan identified a unilateral left adrenal mass. A subsequent CT scan of her chest, abdomen, and pelvis for surgical planning and tumour staging confirmed the left adrenal mass, a normal right adrenal gland, and identified a 3 mm left upper lobe lesion of the lung. The infant underwent a transperitoneal left adrenalectomy and developed adrenal insufficiency post-operatively. Histopathological examination of the adrenal mass confirmed a well encapsulated cortical adenoma with a maximum dimension of 45 mm and weight of 9.8 g. The virilisation symptoms improved following surgical excision and she commenced adrenal replacement therapy. Keywords: Adrenocortical adenoma, Paediatric surgery, Paediatric oncology, Endocrine disorders of childhood, Androstenedione, Functional adrenocortical neoplasia, Virilisation in childhood

Purpose This article describes the development of a new reproductive tissue cryopreservation clinical service for children at high risk of infertility in the NHS during times of severe financial constraints in the health service. Method A development plan with two phases was drawn up. Phase 1 restricted the service to childhood cancer patients referred to the Oxford Paediatric Oncology and Haematology Principle Treatment Centre. It was estimated that there would be 10 patients/year and used existing staff and facilities from paediatric oncology, surgery, anaesthetics radiology, pathology, psychology, teenage–young adult gynaecology, and an existing Human Tissue Authority tissue bank with a licence for storage of tissue under a Human Sector Licence. Phase 2 extended the service to include children and young adults across England, Wales and Ireland—patients from Scotland having access to a research programme in Edinburgh. The main challenge in phase 2 being resources and the need for patients to be able to be treated as close to home as safely as possible. Results The Oxford team developed information resources and eligibility criteria based on published best practice, referral and treatment pathways, multidisciplinary team meetings, a network of third party sites, and a dedicated case management and database. As the programme expanded, the Oxford team was able to justify to management the need for a dedicated theatre list. Patient feedback through questionnaires, qualitative work conducted as part of a Ph.D. thesis as well as direct patient stories and interviews in TV, and radio features underpins the positive impact the programme has on patients and their families. Conclusion The Oxford Reproductive Cryopreservation programme delivers fertility preservation treatment to children and young adults at high risk of infertility safely, effectively and as close to home as possible. The onward view is to apply for national funding for this programme for recognition and sustainability.

Objective This paper describes the fellowship programme of the International Affairs Committee of the British Association of Paediatric Surgeons. Patients and methods The selection of low-income and middle-income country (LMIC) fellows from 2005 to 2016, their funding, experience, and current roles are described. Qualitative and quantitative analysis was performed. Results Thirty-eight trainees from 21 LMIC were awarded fellowships over the 11-year period. Thirty-two have completed the fellowship at time of writing, all are now in consultant positions. Obtaining a visa was the single most cited barrier to starting the fellowship. Twenty completed the questionnaire. Hundred percent felt the fellowship had contributed to personal development and 71% had altered clinical practice subsequent to their experience. Thirty-three percent have gained research opportunities. Conclusion This evaluation supports LMIC-high-income country partnerships and highlights the benefits of fellowships to both the individual surgeon, their department and patient population. Keywords : BAPS, fellowship, low- and middle-income country, partnership

Congenital airway pulmonary malformations are increasingly being diagnosed, but their management continues to remain controversial. Our approach has been to offer surgery to mitigate the risk of infection and possible malignancy. All patients routinely undergo a CT scan of the chest postnatally and once the diagnosis is confirmed, minimal access surgery is offered. Our anesthetists provide single-lung ventilation to enhance the operative view. We conducted a retrospective review over a 10-year period, during which 91 patients were prenatally suspected to have a cystic lung lesion. There were 88 live births of which 29 (33%) cases were initially managed conservatively based on CT findings. Five of these patients, however, became symptomatic needing surgery. A total of 64 (73%) patients underwent surgery with the most common lesions being congenital pulmonary airway malformations (CPAMs) (24), hybrid lesions (19), and pulmonary sequestrations (12). The median age at surgery was 5 months (1 day to 17 months). Using a minimal access approach, 41 (64%) cases were completed with 17 performed open from the onset. Open surgery was indicated in neonates who became symptomatic within the first few weeks of life as well as patients in respiratory distress that would not tolerate either single-lung ventilation or gas insufflation. There were six further conversions to open from minimal access surgery due to poor visualization or technical difficulties. One patient needed a perioperative blood transfusion and one patient had a more prolonged stay due to persistent air leak managed conservatively. Among asymptomatic patients, evidence of microscopic disease was seen, which included infection as well as two cases of tumors, one pleuropulmonary blastoma seen as part of a CPAM, and one rhabdomyomatous dysplasia seen in the CPAM component of a hybrid lesion. In our experience, excising asymptomatic lesions is safe with minimal complications. Single-lung ventilation in combination with thoracoscopy provides excellent vision. There is a risk of infection and a definite, albeit low, risk of malignancy, which may outweigh the benefits of conservative management.

Aims This study aims to determine the rate of prenatal detection of tracheoesophageal fistula and oesophageal atresia (TOF/OA), by identifying a small or absent stomach bubble with or without polyhydramnios, on the prenatal ultrasound scans (USS). Methods A retrospective study of prenatal ultrasound findings of babies with a prenatal and postnatal diagnosis of TOF/OA born between 1st January 2004 and 31st December 2013 was undertaken. Results A total of 58 babies were born with TOF/OA. 40% of mothers had their prenatal investigations performed within our tertiary centre, and the remaining 60% had their antenatal care at their local district general hospital (DGH). The overall sensitivity for prenatal USS was 26%, with a specificity of 99% and a positive predictive value (PPV) of 35%. However, the sensitivity of the prenatal USS within the tertiary centre was significantly higher at 57%, while only 2 cases were detected prenatally in the DGHs. Polyhydramnios was seen in 67% of mothers that had a prenatal diagnosis of TOF/OA and its presence did significantly increase the positive predictive value of prenatal USS (from 35% to 63%). Of those that were postnatally diagnosed, 21% had prenatal polyhydramnios. There was no significant difference in postnatal outcomes between those that were prenatally diagnosed and those that were postnatally diagnosed. Conclusion Prenatal diagnosis of TOF/OA remains challenging. However within a specialist centre the accuracy of successful prenatal detection can be significantly improved. This is beneficial both for prenatal counselling of families and for planning appropriate perinatal and postnatal care for the baby.

Necrotising enterocolitis (NEC) is a neonatal surgical emergency. At its early stages, the management of NEC is largely medical using broad-spectrum antibiotics, gut rest and total parental nutrition. The only absolute indication for surgery is an intra-abdominal perforation. There are several relative indications for surgery based on clinical, biochemical and radiological parameters. Once the decision to intervene is made, several approaches may be taken. Peritoneal lavage can be used as a salvage procedure or definitive management in some cases. The most common approach taken is bowel resection with enterostomy formation. There is a role for primary anastomosis of bowel in limited NEC. In severe, multi-focal NEC a high diverting jejunostomy or "clip and drop technique" can be used. Laparoscopy has a limited role and is not widespread. The surgical complications of NEC include stoma related morbidity, anastomotic leak/stricture and short-bowel syndrome. Long-term data on neurodevelopmental outcomes is sparse but the present literature is suggestive of a negative impact in cases of surgically managed NEC.

Objectives This study aimed to create a snapshot picture of the global workload of paediatric surgeons and identify differences between countries. Methods Surgeons from 13 paediatric surgical units in different countries across the world were asked to record the number and type of admissions to the paediatric surgery service over a 24-h period from 8 a.m. on 23 May 2012. Results Data were recorded for 13 units from 13 countries: 11 low and middle income countries (LMICs) and two high-income countries (HICs). Dar es Salaam, Tanzania, had the greatest number of admissions. Two units in HICs had the lowest number of admissions, other than the Nigerian unit, which only had three admissions due to a hospital strike on the day surveyed. The percentage of emergency admissions ranged from 38 to 83%. Those units with the highest number of total admissions tended to also have the highest proportion of emergencies. Trauma was the most frequently reported admission reason, accounting for 18% of admissions. However, there were no cases of trauma in HIC units. Conclusion The spectrum of paediatric surgery differs between countries, in particular between LMICs and HICs. Units in LMICs tend to have a greater number of admissions, including a wider variety of conditions and a higher proportion of emergency work. Paediatric surgery in LMICs faces many challenges. This highlights the importance of training specialist paediatric surgeons in these countries. Further data are still needed to fully outline the burden of disease in paediatric surgery, especially in LMICs. Keywords : epidemiology, global surgery, paediatric surgery

In the published version, the Acknowledgements section was missing a funding note of co-author Dr C Verrill. The corrected version should read as follows.

Objective The aim of our study was to determine the timing of referrals and the outcome of undescended testes (UDT) over a 4-year period in a tertiary centre in England, and to compare this with a similar centre in Nigeria. Background data Cryptorchidism is a recognized cause of infertility and a key risk factor for testicular malignancy. Current recommendations are that orchidopexy be performed between 12 and 18 months of age; however, there is no consensus on this.Materials and methods Data were obtained for orchidopexies performed between 2003 and 2007 from a tertiary referral centre in England. A standardized proforma was used to collect data into an Excel database, which was analysed and compared with data from a similar centre in Nigeria.Results Eighty-eight patients from a tertiary referral centre in England underwent surgery for UDT. Fifty-six (63.6%) patients were referred and 38 (43.2%) patients were operated on within 2 years of age. Doctors and health visitors accounted for 69 (78.5%) referrals to the tertiary centre. Data from Nigeria demonstrated that of the 61 cases, 13 (21%) patients presented and 11 (18%) patients were operated on by 24 months. Referral beyond 60 months of age in the English series was due to ascending testis, whereas in the Nigerian study, the delayed presentation was due to delayed referral from lack of knowledge of the condition.Conclusion In England and Nigeria, there is a lack of definitive guidelines relating to the appropriate age of referral of patients with UDT. A structured care pathway is needed to enable early detection and definitive management.

Introduction: Necrotizing enterocolitis (NEC) is a serious gastrointestinal emergency in newborn infants. Surgical management includes primary peritoneal drainage and/or exploratory laparotomy with bowel resection. This study describes obstetric complications, postnatal comorbidities, surgical care and intermediate postoperative outcomes in all infants with surgically and/or histologically proven NEC, who underwent exploratory laparotomy at our tertiary referral centre. Materials and methods: We conducted a retrospective review between January 2005 and December 2010. Results are reported as median (range). Fisher’s exact test (two tailed) was used for statistical analysis. A P -value of 0.05 or less was considered statistically significant. Results: A total of 71 infants had suspected (Bell’s stageZ1) NEC. Of them, 32 infants underwent laparotomy for stage 2–3 NEC. We excluded 11 infants with surgically and/or histologically proven spontaneous intestinal perforation. In the remaining 21 infants with confirmed NEC, median gestational age was 27 weeks (23–39 weeks) and median birth weight was 720 g (440–3510 g). NEC was suspected after a median 14 days of life (1–49 days of life). Fifteen patients (71%) were initially managed medically for a median total of 8 days (1–25 days). Laparotomy was performed after a median of 7 days (

Background: To emphasise the value of on-going commitment in Global Health Partnerships. Materials and Methods: A hospital link, by invitation, was set up between United Kingdom and Tanzania since 2002. The project involved annual visits with activities ranging from exchange of skill to training health professionals. Furthermore, the programme attracted teaching and research activities. For continuity, there was electronic communication between visits. Results: Six paediatric surgeons are now fully trained with three further in training in Africa. Paediatric surgery services are now separate from adult services. Seven trainee exchanges have taken place with four awarded fellowships/scholarships. Twenty-three clinical projects have been presented internationally resulting in eight international publications. The programme has attracted other health professionals, especially nursing and engineering. The Tropical Health and Education Trust prize was recently achieved for nursing and radiography. National Health Service has benefited from volunteering staff bringing new cost-effective ideas. A fully funded medical student elective programme has been achieved since 2008. Conclusion: Global Health Partnerships are an excellent initiative in establishing specialist services in countries with limited resources. In the future, this will translate into improved patient care as long as it is sustained and valued by long term commitment.

Background The Lancet Commission on Global Surgery reported that 5 billion people lack access to safe, affordable surgical care. The majority of these people live in low-resource settings, where up to 50% of the population is children. The Disease Control Priorities (Debas HTP, Donkor A, Gawande DT, Jamison ME, Kruk, and Mock CN, editors. Essential Surgery. Disease Control Priorities. Third Edition, vol 1. Essential Surgery. Washington, DC: World Bank; 2015) on surgery included guidelines for the improvement of access to surgical care; however, these lack detail for children's surgery. Aim To produce guidance for low- and middle-income countries (LMICs) on the resources required for children's surgery at each level of hospital care. Methods The Global Initiative for Children's Surgery (GICS) held an inaugural meeting at the Royal College of Surgeons in London in May 2016, with 52 surgical providers from 21 countries, including 27 providers from 18 LMICs. Delegates engaged in working groups over 2 days to prioritize needs and solutions for optimizing children's surgical care; these were categorized into infrastructure, service delivery, training, and research. At a second GICS meeting in Washington in October 2016, 94 surgical care providers, half from LMICs, defined the optimal resources required at primary, secondary, tertiary, and national referral level through a series of working group engagements. Results Consensus solutions for optimizing children's surgical care included the following:An “Optimal Resources” document was produced detailing the facilities and resources required at each level of care. Conclusion The Optimal Resources document has been produced by surgical providers from LMICs who have the greatest insight into the needs and priorities in their population. The document will be refined further through online GICS Working Groups and the World Health Organization for broad application to ensure all children have timely access to safe surgical care.

The aim of this study was to establish the post-natal diagnosis and outcome of antenatally diagnosed intra-abdominal cysts between 1991 and 2013 at our institution.All antenatally diagnosed intra-abdominal cysts between 1991 and 2013 were identified using a foetal anomaly database. The cysts were monitored for resolution. In all cases where the cyst had not resolved antenatally, additional post-natal scans were conducted. Antenatal diagnosis, post-natal diagnosis and outcomes were also recorded.118 cases of antenatal intra-abdominal cysts were identified over the 22-year study period with a 98 % live birth rate. The overall accuracy of an antenatal diagnosis at our institution was 92 %. 26 cases (22 %) resolved spontaneously in utero, the majority of which (77 %) were ovarian in nature. Four tumour cases were identified in the series, which included two neuroblastomas, one yolk sac tumour and one teratoma. 90 cysts persisted post-natally with 52 % requiring surgery. These primarily included choledochal and enteric duplication cysts as well as symptomatic solid organ cysts. Diagnostic revision was limited to 8 % of cases over the study period with an overall improvement over the last decade. Overall, 40 % of all antenatally diagnosed cysts required surgical intervention. In those cysts that persisted post-natally, 52 % required surgery.A fifth of prenatally diagnosed intra-abdominal cysts will resolve with most ovarian cysts regressing in utero. Half of all persistent cysts will, however, require surgical intervention. These data are useful for prenatal counselling and demonstrates the important role played by the paediatric surgeon in the overall management of intra-abdominal cysts.

Background: The literature on paediatric osteomyelitis in the developing world is scarce, and there have been calls for further characterisation of its epidemiology and the identification of factors that limit effective management in order to guide local service delivery. Our centre is a hospital serving a population of 11 million people in Tanzania. Materials and Methods: We identified patients 3 months. Twelve out of 13 with a time from symptom onset to presentation of

Background: Clinical research forms the cornerstone of efforts to improve the lives of patients. African Journal of Paediatric Surgery has been a major vehicle for dissemination of information to paediatric surgeons in Africa since 2004. Most studies in the paediatric surgical literature are observational studies. This study aims to assess the adequacy of clinical research reporting in African Journal paediatric surgery.Materials and Methods: The authors analyzed all observational studies published in African Journal of Paediatric Surgery from 2006 to 2010 (n = 73). Studies were assessed using a validated tool for 16 baseline criteria essential for the non-biased reporting of clinical data (details regarding surgeons, cases, interventions, and statistical methods). Seven additional criteria pertaining to comparison methods were assessed in studies using controls. Results: Sixty-seven percent of all studies were retrospective, and only5.5% utilized a control group. There were 72 (98.6%) case series. Most studies met less than half of the essential reporting criteria (mean, 7.3 of 16 baseline criteria). Reporting defi ciencies were found in all major aspects of study design and statistical analysis. There is no statistical difference between prospective and retrospective studies.Conclusions: This study has identifi ed defi ciencies in the fundamental elements essential to non-biased reporting of clinical research in African Journal of Paediatric Surgery. We recommend that the Journal adopt the validated standard reporting criteria for these studies to improve the ability of its readers to interpret the relevance of clinical research findings to their own practice.Key words: African Journal of Paediatric Surgery, clinical research, observational studies, reporting

Foetal counselling is best achieved by a multidisciplinary team that can favourably influence the perinatal management of prenatally diagnosed anomalies and provide this information to prospective parents. Prenatal diagnosis has remarkably improved our understanding of surgically correctable congenital malformations. It has allowed us to influence the delivery of the baby, offer prenatal surgical management and discuss the options of termination of pregnancy for seriously handicapping or lethal conditions. Antenatal diagnosis has also defined an in utero mortality for some lesions such as diaphragmatic hernia and sacrococcygeal teratoma so that true outcomes can be measured. The limitation of in-utero diagnosis cannot be ignored. The aim of prenatal counselling is to provide information to prospective parents on foetal outcomes, possible interventions, appropriate setting, time and route of delivery and expected postnatal outcomes, immediate and long term.

Teratomas are composed of multiple tissues foreign to the organ or site in which they arise. Their origin is postulated by 3 theories one of which is the origin from totipotent primodial germ cells. Anatomically, teratomas are divided into gonadal or extragonadal lesions and histologically they are classified as mature or immature tumors. Teratomas are mainy isolated lesions and may occur anywhere in the body. In the neonatal age group most of these tumors are benign and occur mainly in the sacrococcygeal area followed by the anterior mediastinum. Diagnosis is usually established prenatally and may require intervention in compromised fetuses. Postnatal imaging with ultrasound, CT scan or MRI provides useful information for surgical intervention. Complete surgical excision is the treatment of choice for neonatal teratomas. Alpha feto protein is the tumor marker of choice and is particularly useful for assessing the presence of residual or recurrent disease.

Neonatal surgical problems of the chest include a wide spectrum of anomalies that extend from chest wall deformities to developmental cardiac malformations. Many chest conditions have other associated anomalies such as chromosomal anomalies that may form part of more complex syndromes. In the era before prenatal diagnosis many of these conditions would present as fetal loss or asymptomatically and discovered incidentally during postnatal imaging. Prenatal diagnosis has revolutionised the diagnosis and treatment of these conditions. Congenital lung lesions have a prenatal diagnostic accuracy of almost 100% and are mainly asymptomatic at postnatal presentation. The diagnosis may be confirmed on postnatal computerised tomography (CT) scan, however the treatment of these asymptomatic lesions remain controversial. Most institutions offer surgery however surveillance with CT imaging is the alternate management. Chylothorax and thoracic teratoma are other thoracic conditions discussed. More than 60% of cases that are prenatally diagnosed with congenital diaphragmatic hernia, do not make it beyond the neonatal period. Complex associated anomalies and lung hypoplasia are the prime causative factors for this grim outcome. Even those infants that survive post surgical repair, some will have respiratory, gastrointestinal or neurological sequeli. Diagnosis of oesophageal atresia is less accurate on prenatal scan. Surgery could be challenging and outcomes are dependent on associated anomalies.

Rhabdomyosarcoma (RMS) is the most common soft tissue tumour in children. This is the first time a facial RMS metastatic to the pancreas is reported. The patient was a 3-year-old boy with a symptomatic solitary pancreatic metastasis of a primary facial RMS, with already one relapse in a submental lymph node. Since this was the second relapse of the disease and due to the extensive nature of the mass, the patient was considered for palliative care and a bypass procedure with a choledochojejunostomy, a gastrojejunostomy and a cholecystectomy was performed. The patient expired 6 months later.

Exomphalos is a midline defect, with a viable sac composed of amnion and peritoneum containing herniated abdominal contents with an incidence of about 1 in 4,000 live births. Associated major abnormalities can be karyotypic, syndromic or structural in up to 70% of cases. The aim of this study is to determine the factors that influence survival of antenatally diagnosed exomphalos. All antenatally diagnosed and postnatally confirmed exomphalos registered with our fetal medicine unit, during 2002–2007, were reviewed. Both prenatal and postnatal outcomes were analysed. Of 88 cases identified with exomphalos, 85 were prenatally diagnosed. Fifty-five of them died in utero (45 terminations, 5 spontaneous abortions and 5 still births). There were 33 live births (37.5%), 7 of which were premature (30–35/40 gestation). Five babies died before coming to surgery (all with major exomphalos as well as abnormal karyotype) while 28 were operated upon. Fourteen cases with minor exomphalos, all isolated, were primarily closed and all survived to discharge. Of 14 babies with major exomphalos, 4 were closed primarily. Nine required silo formation and six successfully underwent secondary closure (one of which had a prenatal diagnosis of giant ruptured exomphalos). Three died before closure, two from sepsis and multi-organ failure, and one from an undiagnosed tracheo-oesophalgeal cleft. All three deaths had antenatally diagnosed giant ruptured exomphalos and were less than 34/40 weeks gestation. One baby was managed conservatively with antiseptic solution applied to the sac and left to heal by secondary intention. There were 17 cases of isolated exomphalos (with no other structural abnormalities), all of which survived. Antenatal diagnosis of exomphalos is 96% sensitive. Severe karyotypic and structural abnormalities were present in all intra-uterine and early postnatal deaths. Overall survival to discharge was 28%. Both minor and isolated exomphalos carried a good prognosis. Isolated exomphalos was a better prognostic factor than severity of the exomphalos itself. Ruptured giant exomphalos were associated with a poorer outcome especially in premature babies.

Aims of study Epidermal growth factor (EGF) is an amino acid polypeptide that has been shown to promote mucosal healing and intestinal growth in experimental models and has a potential role in the aetiology and treatment of NEC. The aim of this study was to determine the normal levels of salivary EGF in a cohort of healthy neonatal infants. Material and methods With appropriate ethical approval and informed consent, saliva was collected using a suction catheter from all normal neonatal infants admitted to our unit over a 9-month period. The samples were immediately frozen at - 20 degrees C and analysed using an ELISA assay (R & D Systems, Oxford, UK). Samples taken a week prior to and two weeks following a septic episode (as diagnosed by clinical or biochemical evidence) were excluded. Patients with congenital malformations and chromosomal anomalies were excluded. Results A total of 65 samples were collected and analysed from 27 babies. The mean gestation and weight of the patients was 32.2 (+/- 5.50) weeks and 1954.44 (+/- 1045.7) grams, respectively. Five samples from 2 infants were discarded. None of the patients in whom the samples were analysed had clinical or serum markers of sepsis or NEC. All infants were given maternal breast milk starting at the mean age of 5 (+/- 3.47) days. The mean EGF values were 676.95 (+/- 168.47) pg/ml. There was a significant rise in serial salivary EGF values in patients (p = 0.0019). There was no correlation between the EGF values and gestation (R = 0.35, p = 0.08). The birth weight, sex or timing of initiating enteral feeds did not correlate with EGF values. Conclusion In conclusion, our study shows a rise in salivary EGF values in serial samples in a clearly defined group of healthy infants.

Congenital lung lesions are diagnosed antenatally in the majority of cases. Postnatal management includes chest radiography and CT-scanning, followed by either surgical resection or CT surveillance. Pre-operatively, lesions are often "labelled" as CCAM (and the Stocker classification incorrectly applied), sequestration, or lobar emphysema, and their frequent "hybrid" nature sometimes missed. The aim of our study was to correlate antenatal and postnatal radiological diagnoses and classification of congenital lung lesions with surgical and pathological outcome. Twenty-six consecutive cases of antenatally-diagnosed cystic lung lesions managed at our centre between January 2003 and April 2007 were reviewed. Diagnoses were: cystic adenomatoid malformations (CCAM) in 13 cases (50.0%), three bronchopulmonary sequestrations (11.5%), "hybrid" lesions in eight cases (30.8%), one isolated lobar emphysema (3.8%) and a normal lung segment with anomalous systemic supply (3.8%). Overall concordance rate between prenatal ultrasound and resection pathology was 61.5%, whereas CT findings correlated with pathology in 65.4% of cases. Incorrect radiological classification resulted in one morbidity, when an attempted thoracoscopic resection of a presumed CCAM had to be converted to an open procedure due to bleeding from an unsuspected anomalous vessel. The common embryological origin of these lesions, and the need for standardisation of reporting is discussed. We propose that lesions should be classified anatomically according to their nature, arterial supply and venous drainage in order to reduce discrepancies between radiological, intra-operative and pathological reporting.

Resources for neonatal surgery vary hugely between the developed countries and Africa. Due to the burden of other childhood diseases, neonatal surgery is of low priority to health-care budget holders in the developing countries. Admissions to two linked neonatal surgical institutions in Africa and Europe are compared to draw attention to the need of newborn care in developing countries. In a 3-year period, there have been 528 neonatal surgical admissions to the Kilimanjaro Christian Medical Centre (KCMC), Tanzania. During the same period, 707 surgical neonates were admitted to the John Radcliffe Hospital, UK (JRH). Conditions more commonly seen in the JRH include necrotising enterocolitis (NEC) (10.2 vs 0%), gastrochisis (5.5 vs 0.9%), congenital diaphragmatic hernia (2.4 vs 0.4%), congenital lung cysts (1.6 vs 0.4%), meconium ileus (2.4 vs 0%), malrotation (2.7 vs 0.6%) and abdominal/pelvic cysts (1.1 vs 0%). Conditions more commonly seen in KCMC include anorectal malformation (9.5 vs 4.7%), sacrococcygeal teratoma (2.3 vs 0.3%), Hirschsprung's disease (10.2 vs 4.5%), branchial fistula (0.9 vs 0%), haemangioma (2.1 vs 0%) and cystic hygroma (2.1 vs 1.0%). The spectrum of neonatal surgical admissions in our two institutions varied. We believe this is attributable to availability of antenatal diagnosis, primary health-care, transport facilities, genetics as well as survival of delayed presentation. This study demonstrates the extent and spectrum of neonatal surgical pathology in this part of Africa and highlights the need for newborn surgical care in developing countries.

Anorectal malformations (ARM) remain a significant birth defect with geographic variation in incidence, individual phenotypes and regional geographic subtypes. Although early studies indicated a low incidence in Black patients, there is a great paucity of knowledge as to the types, frequency and incidence of ARMs encountered in the African continent and their associated anomalies. Current evidence suggests a significant clinical load. This study set out to evaluate ARM in Southern and other parts of Africa to define the clinical load of ARM. We retrospectively collected data on 1,401 ARM patients from six South African Paediatric Surgical units plus representative samples from five other African countries from West, Central and Southern Africa. Data included ethnic group, age, gender as well as the anatomical pathology, classification and presence or absence of associated anomalies. ARM lesions classified by the Wingspread classification plus an analysis of fistula position was carried out in evaluable cases for purposes of comparison. South African centres reported a higher prevalence of cloacae and vestibular fistulae, whereas rectovaginal, recto prostatic and anorectal malformation without fistula were more prevalent in the Northern African group. 76% of 1,401 patients were ethnically Black African [gender ratio = 2 (vs gender ratio 1.38 overall)] and 49.8% were "low" lesions (Wingspread classification). High or intermediate lesions were mostly males (72%). Anal stenosis was most prevalent in black males and non-Black females. Fistulae were identified in 95% with 682 (52%) being low (perineal/covered anus/vestibular) fistulae. Perineal fistulae had a male predilection (n = 260; 20%), whereas vestibular fistulas (n = 416; 32%) was strikingly frequent in black females (55%). Of the remainder, 15 fistulae were rectovesical (1.2%), 544 recto-urethral or prostatic (42%), 16 recto-vaginal (1.2%). In addition, there were 43 cloacal lesions (3.3%). Isolated rare ARM anomalies included "Pouch" colon (2) and H-type fistula (2). Isolated lesions occurred in 81% but 163 associated anomalies were identified in 114 patients. These included chromosomal lesions (10), genito-urinary anomalies (50), genital (16), cardiac (31), skeletal anomalies (33), gastro-intestinal malformations (28). Other anomalies included CNS anomalies (14), anterior abdominal wall defects (2) and facial (8) abnormalities and neuroblastoma (1). The ARM is not uncommon in Black African populations and constitutes a significant clinical load to surgical practice in Africa. Ethnic differences appear to exist and vestibular fistulae predominate in black females. Cloaca (3.3%) did appear to be more prevalent. Isolated lesions are frequent but the types of associated anomalies appear similar to other series except chromosomal syndromes. This study illustrates the need for more objective data from developing countries to assess geographical differences.