Appendicitis and male circumcision top children's procedures outside paediatric hospitals

Appendicitis surgery is the most common procedure carried out on children outside of speciality paediatric hospitals, a new study shows.

Male circumcision was the second most common procedure performed during the two-year study period with 67 (15.5% of all procedures) in 2015 and 90 (16.5% of procedures) in 2016.

The study, carried out at Regional Hospital Mullingar, and published in the Irish Medical Journal, highlights that paediatric general surgery can be safely and efficiently performed by staffed and resourced Model III (regional and country) hospitals.

Data was collated by examining the Hospital In Patient Enquiry (HIPE) system and In Patient Management System (IPMS). All elective and emergency general surgical admissions to the paediatric ward were analysed .

Ireland has the lowest number of paediatric surgeons per capita when compared to other European countries, despite having the highest birth rate in Western Europe.

In 2016 the Faculty of Paediatrics in the Royal College of Physicians of Ireland, in conjunction with the Royal College of in Surgeons Ireland and the Health Service Executive, published the National Clinical Programme for Paediatrics and Neonatology: improving services for general paediatric surgery.

The purpose of these guidelines was to ensure the provision of safe and efficient paediatric general surgery outside of specialist paediatric hospitals in both local and regional paediatric surgical facilities.

These guidelines were introduced due to a variety of factors including the retirement of a generation of consultant surgeons with paediatric surgical skills and a lack of paediatric surgical training for core trainees.

There is also an increasing sub-specialisation within the field of general surgery which has resulted in the de-skilling of supporting anaesthetic, radiology and nursing colleagues, and inadequate funding of paediatric surgical services.

The Regional Hospital Mullingar, which serves a total population of 291,000, was chosen for the study, as it has a high demand for general paediatric surgical services. The study aim was to examine the volume and outcomes for paediatric general surgery in a model III hospital (regional and general) catering for children aged older than 12 months.

In the retrospective review of paediatric surgical admissions performed from January 2015 to December 2016, at Regional Hospital Mullingar, figures show that operative procedures in most units (nationwide) is limited to appendicectomy, circumcision, herniotomy (hernia), orchidopexy (move an undescended testicle into the scrotum and permanently fix it there), as well as lesion excision and abscess drainage.

The study reflected these findings, with just 10 procedures accounting for 70.6% of procedures performed across two years. The low overall re-admission rates across the study period illustrates the safe, effective service that is provided by this regional hospital.

During the period of the study, there was a total of 2,079 surgical admissions.

At the county Westmeath hospital up to 575 (27.2%) were elective and 1,504 (71.2%) were emergency admissions. Significantly more surgical procedures were performed in 2016 at 546 or 56% versus 433 or 44.2% in 2015. Laparoscopic appendicectomy was the most commonly performed procedure.

Nine hundred and seventy nine procedures were performed on children 15 years and under in the two year period with significantly more being performed in 2016.

In 2015, the majority of admissions were male at 587 or 61.4%, versus 369 or 38.6% for females. A similar trend was also noted for 2016 with 711 or 63.3% males versus 412 or 36.7% for females.

Among the surgical admissions, 597 (28.7%) were under the age of five, 700 (33.7%) were between five and 10-years- old and 782 (37.6%) were aged greater than 10 years and less than 16 years of age.

'Difficult to replace our current service providers in regional hospitals'

Doireann Joyce, co-author along with six others pointed out that, “The potential for improvement of the paediatric general surgical services is dependent on the future sustainability of the service.

“The inevitable retirement of surgeons with general paediatric surgical skills, the lack of mandatory paediatric surgical training for general surgery trainees and the growing trend towards sub-specialisation, mean that it will be difficult to replace our current service providers in regional hospitals.

“Although our service could facilitate the provision of surgical services to children less than one year of age, this unit does not routinely operate on children in this age group. This was a common finding by the National Clinical Programme when reviewing services across the country. Our facility does however routinely operate on children less than two years of age, a cut off shared by most units around the country.

“Inevitable centralisation of general paediatric surgery to tertiary centres will also lead to de-skilling of anaesthesia and nursing staff, further compounding this issue.

“This study verifies that correctly staffed and resourced model III hospitals provide safe and effective paediatric general surgical services. They are a key component of the national service that should not be allowed to diminish.

“We conclude that formal teaching of surgical trainees around these core general paediatric surgical competencies would be possible with mandatory rotations through regional hospitals providing these services.

“This initial training could be supplemented with rotation through tertiary paediatric centres late in the training scheme for those interested in this subspecialty.

“This would have positive implications for the future of general paediatric surgery in Ireland, limiting the inevitable dependence on tertiary referral centres.”

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