PEDIATRIC SURGERY OUTCOMES IN LOW AND
MIDDLE-INCOME COUNTRIES IN AFRICA:
A SCOPING REVIEW OF THE RECENT LITERATURE
Michael Livingston
Jennifer DCruz,
Julia Pemberton
Doruk Ozgediz
Dan Poenaru
BACKGROUND
• Essential surgical care is cost effective and a “good buy” in
resource-constrained environments
• BUT many outcomes of pediatric surgical conditions in
Africa are unknown
OBJECTIVES
• Identify and describe the recent literature related to:
Outcomes of major procedures
in pediatric surgery…
in Low and Middle-Income Countries…
in Africa
• Recommend areas for future research
METHODS
SCOPING REVIEW
1. Major surgical procedure
2. Less than 18 years
3. Reports outcomes
4. Minimum 5 participants
5. Minimum 30 days of follow-up
6. Published between 2007-2012
7. Low or lower middle-income
country in Africa
SEARCH STRATEGY
• Electronic databases:
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Medline
Embase
Cochrane Library
Global Health
ProQuest Dissertations & Theses
PapersFirst
Zambia Forum for Health Research Database
• Relevant conferences:
• Pan African Pediatric Surgical Association
• College of Surgeons of East Central and Southern Africa
RESULTS
2801 records identified
through database search
230 records identified through
manual conference search
3031 records identified
through database search
946 duplicates excluded
2085 records screened
1793 records excluded
292 full-text records
assessed for eligibility
183 records excluded
109 records in final analysis
WHERE WERE STUDIES COMPLETED?
Egypt (11%)
>10 studies
1-10 studies
0 studies
Nigeria (48%)
Not included
WHY SO MANY STUDIES FROM EGYPT
AND NIGERIA!?
POPULATION
* Chirdan LB, Ameh EA, Abantanga FA, et al. Challenges of training and delivery of pediatric
surgical services in Africa. J Pediatr Surg 2010;45:610-8.
WHICH CONDITIONS?
Congenital (63%)
1. Anorectal Malformations (12%)
2. Hirschsprung’s Disease (10%)
3. Hydrocephalus (9%)
Both (7%)
Acquired (44%)
1. Tyhpoid Ileal Perforation (9%)
2. Intussusception (6%)
3. Corrosive Esophageal Injury (4%)
WHICH OUTCOMES?
Wound Infection (32%)
Both (20%)
Mortality (62%)
Neither (26%)
WHICH STUDY DESIGNS?
• Almost all studies (98%) used an observational design:
• Cross-sectional studies
• Cohort studies
• Case series
• Two studies (2%) used an experimental design…
POPULATION
• Randomized controlled trial from Togo from 2010
• Compared 2 techniques for the treatment of typhoid
intestinal perforation
VS
Primary Anastomosis (n=18)
(with or without ileostomy)
Ileocolic Intubation (n=22)
(overlapping anastomosis)
• Similar length of stay between groups
• Much higher post-operative complications with primary
anastomosis (53%) than with ileocolic intubation (5%)
CONCLUSIONS
SUMMARY OF FINDINGS
• High quality pediatric surgery research in low and
middle income countries in Africa is possible
• Nigeria and Egypt are the epicenters of activity with
smaller pockets in west and southeast Africa
• Research activities appear to reflect the unique needs
and conditions of this environment
LIMITATIONS OF THIS REVIEW
• Only studies reported in English and French were included
• Many studies were excluded due to:
• Small numbers (less than 5 participants)
• Short follow-up (less than 30 days)
• Significant heterogeneity in description of outcomes
made data abstraction and pooling difficult
RECOMMENDATIONS FOR FUTURE
RESEARCH
POPULATION
• Outcomes of research studies should be clearly defined
and reported
• Rates of mortality and wound infection following surgical
interventions should be reported whenever possible
• BUT interventions that target morbidity should report
measures of disability and quality of life
THANKS FOR LISTENING!