Epidemiological Aspects of Diseases Seen in Pediatric Surgery Consultation at the Kara Teaching Hospital ()
1. Introduction
The first pediatric surgery department was created in Togo in 1987. Until 2015, this department was the only one in the country before campus one was created [1]. Despite this, access to pediatric surgical health care for populations in the north of the country was increasingly difficult. Thus, in July 2019, a pediatric surgery department was created at the Kara Teaching Hospital in the north of the country [2]. After its creation, the first consultation took place on 30 October 2019.
The pediatric surgery in developing countries such as Togo faces serious problems of inadequate infrastructures and equipment. To put it, Grosfel et al. [3] said that nowhere in the world is the global burden of surgical diseases more evident than in Africa. They declare that in developing countries, paediatric surgery suffers from inadequate infrastructure, financial resources and government support [3]. This situation has recently been aggravated for almost two years by the health crisis of the COVID-19 pandemic. The lack of financial resources, despite sometimes the manifest goodwill of some hospital administrators, forces them to require prioritization of the equipment to be acquired. The prioritization of its equipment, which depends primarily on the nature of pediatric surgical emergencies, also takes into account the epidemiology of pediatric surgical conditions. It is in this context that this study is initiated, with the aim of taking stock of the epidemiological distribution of pediatric surgical diseases.
2. Material and Methods
This was a retrospective and descriptive study over a period of eighteen months, from October 30, 2019 to April 30, 2021. It took place in the pediatric surgery department of the Kara teaching hospital. This period corresponds to the first eighteen months of activity of the department. Indeed, after its creation on July 5, 2019 [2], the first consultation took place in the service, on October 30 of the same year. The study focused on cases of children of both sexes, aged 0 to 15 years, reported in the service’s consultation register. Only the first consultation was considered for each patient. Consultations take place on Monday afternoons from 3 p.m. and Wednesday mornings from 8 a.m. They are all made by the only pediatric surgeon in the department. Epidemiological parameters were studied. Statistical analyses were done by chi-2 tests (p < 0.005).
3. Results
In eighteen (18) months, two hundred and fifty-nine children were seen in pediatric surgery consultation at the Kara teaching hospital. The annual frequency of consultations was 172.66. The monthly frequency was 14.39. Figure 1 shows the monthly distribution of consultations over the eighteen months.
The average age of the children was 4.56 years with extremes of 2 days and 15 years.
There were 194 boys (74.90%) and 65 girls (25.10%).
At the consultation, whatever the reason, the examination was normal in 17 children and 242 children had abnormalities. Two hundred and twelve children (81.85%) had each one abnormality and 30 children (11.58%) had each at least two. A total of 298 diseases were reported in the 242 children. These were 218 congenital diseases (73.15%) and 80 acquired diseases (26.85%). The difference between congenital and acquired diseases conditions at consultation is statistically significant with p = 0.0041. Table 1 shows the distribution of congenital diseases according to the regions or systems concerned.
Head and neck malformations (n =15): They were composed mainly of cleft lip in 8 cases (53.33%), followed by fibromatosis Colli in 2 cases (13.33%). The other ailments which were gill fistula, right eyebrow leptomeninges cyst, sublingual cyst, supernumerary ear and tongue frenulum were each depicted once.
Limb malformations (n =55): They were dominated by knee deviations in 27 cases (49.09%), followed by hand and foot malformations in 20 cases (36.36%). Congenital radioulnar synostosis (Figure 2) came in third place with 2 cases (3.67%) followed by tibial aplasia (Figure 3) with also 2 cases (3.67%).
Other congenital anomalies such as hypoplasia of the femur, unequal length of the lower limbs, generalized achondroplasia and congenital elbow flexum were each represented by 1 case (1.89%).
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Figure 1. Distribution of consultation staff by 18 months of the study period.
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Table 1. Distribution of congenital diseases by region or system concerned.
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Figure 2. Congenital proximal radioulnar synostosis in a 7-year-old boy.
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Figure 3. Type IIb tibial aplasia in a 6-month-old infant.
Knee deviations were a knee recurvatum in 11 cases, a valgum knee in 14 cases and a varum knee in 2 cases.
Urological malformations (n =81): Abnormalities of the peritoneovaginal canal and Nück’s cala were the most represented with 48 cases (59.26%), followed by testicular descent abnormalities with 19 cases (23.47%). Hypospadias ranked third with 7 cases (8.64%) before renal multicystic dysplasia with 2 cases (2.47%). The valves of the posterior urethra, the ectopic mouthing of the ureter, the micropenis, the epididymal cyst and the small congenital bladder were each represented once.
Malformations of the digestive system (n =9): They were divided between anorectal malformations with 2 cases (22.22%) and Hirschsprung’s disease with 7 cases (77.77%). Figure 4 shows a nine-year-old boy seen for chronic constipation in Hirschsprung’s disease.
Abdominal wall malformations (n =53): These were only umbilical hernias in the 53 cases (100%).
Other malformations (n =5): 2 cases of subcutaneous hemangioma and 1 case for Poland syndrome, spina bifida and cystic lymphangioma of the neck were noted, respectively. Acquired ailments were also varied. Table 2 shows the distribution of acquired diseases according to the regions or devices concerned.
Limb trauma, infectious diseases and urogenital conditions were the most represented.
Limb trauma (n =36): These were mostly limb fractures with 18 cases (50%), followed by cerebral palsy with 7 cases (19.44%). Elongation of the brachial
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Figure 4. Nine-year-old boy seen for chronic constipation in Hirschsprung’s disease (note abdominal bloating).
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Table 2. Distributions of acquired conditions by region or system concerned.
plexus was noted in 3 cases (8.33%). Withdrawals of the quadriceps from intramuscular injections and muscle bruises were found in 2 cases (5.55%) each.
Infectious pathologies (n =13): Chronic osteomyelitis was in the lead with 5 cases (38.46%), followed by abscesses of soft parts with 4 cases (30.77%). The other pathologies were a low urinary tract infection in 2 cases (15.38%), a toe infection in 1 case (7.69%) and purulent pleurisy in 1 case (7.69%).
Urogenital disorders (n =7): Coalescence of the labia minora (5; 71.44%), bladder lithiasis (1; 14.28%) and urethral fistula (1; 14.28%) made up this series.
Tumor disorders (n =4): 1 case of osteosarcoma of the right tibia and two cases of exostosis were the tumor pathologies seen in consultation.
Burn sequelae (3 cases), rectal prolapse (3 cases) and postoperative ventrations (3 cases) made up the rest of the series of acquired diseases.
4. Discussion
For the first time in 2019, a pediatric surgery department was created in the northern region of Togo [2]. He is housed at the Kara teaching hospital, which is the reference hospital in the north of the country. Once the administrative act was taken in July 2019, the first consultation took place on 30 October of the same year. Indeed, the pediatric surgeon who was assigned to it was in practice in Lomé, the capital of the country, located 420 kilometers from the city of Kara. The administration of the Kara teaching hospital was not prepared to welcome a new pediatric surgery department. Thus, when the pediatric surgeon started work in August 2019, he could not have an office. This is what has delayed the start of its activities. He was able to make the first consultation on October 30, 2019. This date was the beginning of the study period in our series. Until 2019, Togo’s two pediatric surgery departments were all in the capital Lomé, in the far south of the country. This obviously made access to pediatric surgical care very laborious for the populations of the north of the country. It was therefore important that not only one, but several pediatric surgery departments be created due to at least one per economic region in order to facilitate this accessibility.
The practice of pediatric surgery in developing countries such as Togo is facing serious problems of equipment shortages, aggravated for almost two years by the health crisis of the Covid-19 pandemic. The lack of financial resources, despite sometimes the manifest goodwill of some hospital administrators, forces them to ask for a prioritization of the equipment to be acquired. The prioritization of its equipment, which depends primarily on the nature of pediatric surgical emergencies, also takes into account the epidemiology of pediatric surgical diseases. It is in this context that this study is initiated, to allow us to take stock of the proportional frequency of ailments. These data will situate the opinion on not only the frequency but also the nature of the conditions received in the service. From there, we hope that the needs and their prioritization can be more easily motivated in front of certain decision-makers.
This study was limited to diseases received in consultation. This limitation to the consultation register can be considered as a limit to this study, but we found that it showed the great diversity of pediatric surgical pathologies encountered. Even though most of the children seen in the consultation will be hospitalized at some point, to undergo surgical procedures, the extension of a new study to hospitalized patients can give more reliable figures. Indeed, the pathologies admitted in emergency and hospitalized, for the most part, differ well from those received rather in consultation for which surgical management is often scheduled. Whatever it is, the results of this study are now original and will remain references for the pediatric surgery department of the Kara teaching and the northern region of Togo.
The annual frequency of consultations was approximately 173 in our series. It is very low compared to that reported by Gnassingbe et al. [4] in Lomé in 2010. They had reported about 1434 consultations per year. Indeed, their study focused on the first 20 years of surgical activities of the pediatric surgery department of the Tokoin teaching hospital. This is a great period of study more significant than ours. It is not known that it would have been the annual frequency of consultations during the first two years of operation in this service. In addition to the large study period that does not allow comparison with our study, there is also the fact that the pediatric surgery department in which the study was done was the only one in the country at the time. It was therefore in this department that all cases of pediatric surgery were consulted. Since 2015, a second pediatric surgery department has been created at the Campus teaching hospital in Lomé. It had made it possible to reduce the attendance of the first service. Our pediatric surgery department created in 2019 is the 3rd pediatric service in the country. It is closer to the population of the northern half of the country. In this context, the frequency of consultations may have decreased.
The observation of the consultation curve shows an overall increase over the months. It can be inferred from this that, an increase in consultations over time is to be expected. When consultations increase, hospitalizations will also follow. However, we do not have child inpatient rooms for pediatric surgery. Since the creation of the service, we have shared the same hospital rooms with general surgeons and adult urologists. In addition to the limited space that limits hospitalizations and activities, there is also the fact that, children who will benefit from scheduled surgery may be forced to wait longer. These findings are one more reason to motivate to put at least the minimum for the proper installation of infrastructure and equipment.
Congenital diseases occupied the first place of the pathologies seen in pediatric surgery consultation. They accounted for 73.15%. They dominate the pathologies treated in pediatric surgical departments and can affect all regions and systems of the body. These are abnormalities of structures and or functions, which are present at birth [5] [6]. They may or may not be clinically visible. They represent one of the major causes of infant and neonatal mortality, especially in severe forms [6] [7] [8]. In the United States of America, they are the major cause of infant mortality. [9]. In India, 10% - 15% of newborn deaths are due to congenital diseases [10]. The situation is by no means better in developing countries with high infant mortality rates, related to these malformations [7] [11] [12]. To this end, they represent a real public health problem [5] [7] [8]. The fight to reduce infant mortality from congenital diseases in developed countries has gone through several stages, the main one being the establishment of epidemiological surveillance networks for congenital diseases [9] [13]. Most of these countries have registries of birth defects and potentially teratogenic environmental agents [9]. In most developing countries, such registries are non-existent. Mortality and the incidence of congenital diseases in these countries remain speculative and without any real database. Epidemiological studies have been conducted in Lomé in Togo [4] and Abidjan (Côte d’Ivoire) [7] on congenital diseases, but they have been monocentric. However, they provided a panoramic overview of congenital diseases.
Congenital diseases in our series were dominated by urological abnormalities with 37.16% of cases. The series of Kouamé et al. [7] was characterized by the predominance of osteoarticular malformations. This predominance was found by Kouamé et al. [7] and by other authors [14] - [19]. Some studies, on the other hand, have noted a predominance of neural tube defects [20] [21] [22]. This difference in distribution could be explained by the unknown or known multifactorial origin of congenital diseases [22]. We also believe that the distribution of abnormalities in groups of congenital diseases is not uniform for all authors. As an example, we did not find in the series of Kouamé et al. [7], the abnormalities of the peritoneovaginal canal while they were classified in the urological malformations of our series.
Our study was not limited to congenital anomalies but to all diseases seen at consultation in pediatric surgery department. Thus, it made us possible to note that acquired diseases were for 26.85% of consultations. They were dominated by limb trauma and infectious pathologies including chronic osteomyelitis. Less noisy than acute osteomyelitis, they are mainly characterized by an inexhaustible fistula that often leads to consultation.
Even limited by the study period, this study forms a basis for other more extensive ones that will encompass cases of consultation and hospitalization or that will be multicenter.
5. Conclusion
Pathologies seen in pediatric surgery consultation were dominated by congenital diseases. Urological malformations are the most represented. Even limited by the study period, this study forms a basis for other more extensive ones that will encompass cases of consultation and hospitalization or that will be multicenter.
Ethical Committee Approval
The authors declare having Ethical committee approval for the study.