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Original Investigation |

Surgical Care of Pediatric Patients in the Humanitarian Setting The Médecins Sans Frontières Experience, 2012-2013

Maeve O’Neill Trudeau, MD1,2; Emmanuel Baron, MD3; Patrick Hérard, MD4; Amy S. Labar, MS5; Xavier Lassalle, CRNA4; Carrie Lee Teicher, MD, MPH5; David H. Rothstein, MD, MS6,7,8
[+] Author Affiliations
1Department of Surgery, University of Toronto, Toronto, Ontario, Canada
2Harvard T. H. Chan School of Public Health, Boston, Massachusetts
3Epicentre, Paris, France
4Médecins Sans Frontières, Paris, France
5Epicentre, New York, New York
6Médecins Sans Frontières, New York, New York
7Department of Surgery, University at Buffalo, Buffalo, New York
8Department of Pediatric Surgery, Women & Children’s Hospital of Buffalo, Buffalo, New York
JAMA Surg. 2015;150(11):1080-1085. doi:10.1001/jamasurg.2015.1928.
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Importance  Little is known about the scope of practice and outcomes in pediatric surgery performed by humanitarian organizations in resource-poor settings and conflict zones. This study provides the largest report to date detailing such data for a major nongovernmental organization providing humanitarian surgical relief support in these settings.

Objective  To characterize pediatric surgical care provision by a major nongovernmental organization in specialized humanitarian settings and conflict zones.

Design, Setting, and Participants  A retrospective cohort study was conducted from August 15, 2014, to March 9, 2015, of 59 928 surgical interventions carried out from January 1, 2012, to December 31, 2013, by the Médecins Sans Frontières Operational Centre Paris (MSF-OCP) program in 20 locations, including South Sudan, Yemen, Syria, Gaza, Pakistan, Nigeria, Central African Republic, Democratic Republic of Congo, and the Philippines. Surgical interventions were primarily for general surgical, traumatic, and obstetric emergencies and were categorized by mechanism, type of intervention, American Society of Anesthesia risk classification, and urgency of intervention.

Main Outcomes and Measures  Operative indications, type of intervention, and operative case mortality.

Results  Among all age groups, 59 928 surgical interventions were performed in dedicated trauma, obstetric, and reconstructive centers for 2 years. Nearly one-third of interventions (18 040 [30.1%]) involved preteen patients (aged <13 years) and 4571 (7.6%) involved teenaged patients (aged 13-17 years). The proportion of violence-related injuries in the preteen group was significantly lower than in the teenage group (4.8% vs 17.5%; P < .001). Burns (50.1%), other accidental injuries (16.4%), and infections (23.4%) composed the bulk of indications in the preteen group. Interventions in the teenage group were principally caused by trauma-related injuries (burns, 22.9%; traffic accidents, 10.1%; gunshot wounds, 8.0%). Crude perioperative case mortality rates were 0.07% in the preteen group, 0.15% in the teenage group, and 0.22% in the adult group (>17 years) (P = .001). One-third of the cases (33.4%) were deemed urgent, while most of the remaining cases (57.7%) were deemed semielective (surgical intervention to be performed within 48 hours).

Conclusions and Relevance  When examining surgical interventions in a population of pediatric patients cared for in the specialized setting of humanitarian aid and conflict zones, burns, other accidental injuries, and infection composed the bulk of indications in the preteen group; interventions in the teenage group were principally caused by trauma-related injuries. Crude perioperative case mortality rates in the preteen group were significantly lower than in the adult group. Further work is needed to examine long-term outcomes of pediatric operations in these settings and to guide context-specific surgical program development.

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Types of Surgical Intervention by Age Group

Almost half of the surgical interventions carried out in the preteen group were for wounds (49.4%); the second most common interventions were minor surgical procedures (36.8%). In the teenage group, the most common intervention was wound surgery (30.4%), followed by minor surgical procedures (28.3%). Visceral surgical procedures were performed in 3.4% of the preteen group and 6.8% of the teenage group. Orthopedic interventions were performed in 6.2% of the preteen group and 10.5% of the teenage group. Gynecologic, obstetric, and urologic interventions were rare in the preteen group (0.7%) but increased dramatically in the teenage group (18.6%).

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