Temporal Trends and Spectrum of Pediatric Surgical Conditions Operated In A Tertiary Care Teaching Hospital In Pakistan

Introduction: Knowing the temporal trends as to when and how many pediatric surgery patients present and are operated on in a newly developed unit is crucial in the allocation of resources and policy making in health care center. Aims & Objectives: The aim of this study is to describe the spectrum and pattern of operated pediatric surgery patients in a newly developed pediatric surgical unit of Pakistan. Place and Duration of Study: This study was conducted at Pardiatric Surgery Unit of Holy Family hospital, Rawalpindi between January 2020 and September 2021. Material & Methods: This was a retrospective descriptive study conducted on all patients that were operated under Pediatric surgery unit over a period of 20-months. Data regarding age, sex, diagnosis, and procedure performed were obtained. Diagnoses were categorized based on organ system. SPSS version 22 was used to perform the data analysis., a p-value of (cid:148) 0.05 was considered significant . (cid:3) Results: 898 procedures were performed in total with a male to female ratio of 2.03:1. Most of the patients fell under 2-8 years of age. Digestive system disorders (164, 18.3%) and genitourinary (377, 42%) made most of the cases observed, with inguinal hernias making up to 15.0% of all cases. Oddsratio was calculated for different variables which showed that male patients , patients with gastrointestinal problems had greater odds of being operated. Conclusion: The expected number of operated cases in a newly developed unit is comparable to other units that have been established for a long time.More focus research needs to be done on different aspects of pediatric surgery in our region and to try for integration of pediatric surgery into public health programs including primary and secondary health centers to meet the increasing demand of pediatric surgical patients presented to tertiary


INTRODUCTION
In low-and middle-income countries (LMICs), pediatric surgery is emerging as a growing subspecialty of Surgery 1,2,3 .Holy Family Hospital, Rawalpindi was set up in 1954 as a mission hospital and is affiliated as university teaching hospital with Holy Family Hospital since 1977.It is one of the busiest tertiary care specialized hospitals in region of Northern Punjab.However, no formal pediatric surgical facility was functional until 2016.Since then it is the only teaching hospital providing 1. 1 Department of Pediatric Surgery, Holy Family Hospital, Rawalpindi. 2. 2 Department of Pediatric Surgery, Holy Family Hospital, Rawalpindi. 3. 3 Department of Medicine, Holy Family Hospital, Rawalpindi. 4. 4 Department of Pediatric Surgery, Holy Family Hospital, Rawalpindi. 5. 5 Medical Student, Rawalpindi Medical University, Rawalpindi.

Correspondance:
Dr. Faizan Fazal,Final year medical student,Department of Medicine, Rawalpindi medical university,Rawalpindi.Email: abdalian459@gmail.comSubmission Date: 8 th  elective and emergency services for pediatric surgical patients in this part of the country.The hospital now contains around 40 beds which also includes a Public private partnership funded Step Down Unit consisting of 4 neonatal carts and 3 beds for patients who need oxygen support and critical monitoring.Audit and appraisal of any services has been an important focal point in the quality improvement and clinical governance which include judicial distribution of sources and patient friendly policy making 4 .Although large population is targeted to establish an epidemiological co relation of disease spectrum 5 , disease patterns in pediatric age group can be better studied by studies like these 6,7 .This department is claimed to be the only government tertiary care facility in Northern Punjab entertaining patients from other provinces as KPK and GB, AJK, The aim of this study is to describe the spectrum and pattern of operated pediatric surgery patients in a newly developed pediatric surgical unit of Pakistan.

INTRODUCTION
Globally, acute generalized peritonitis ranks among the top surgical emergencies 1 .It is more common in Third World nations.The prevalence of perforation is low (0.6% -4.9%) in developed nations but high (33% -63%) in West Africa 2 .554 persons were discovered to have peritonitis in a study that took place over three years in India 3 .Researchers in Pakistan have conducted studies with similar methods, with one study reporting 650 cases in a just 9 months 4 .Most cases of peritonitis are caused by a gastrointestinal perforation or anastomotic leak 5 .In the case of peritonitis, anaerobes and gramnegative organisms are mostly responsible for sepsis and morbidity due to the overactive inflammatory cascade brought on by the release of endotoxins 5 .Clinical evidence is used to identify peritonitis.Diagnosis can be achieved via upright plain x-ray of the abdomen, USG, or CT scan.This is often done through diagnostic laparoscopy nowadays 6 .Resuscitation, diagnosis, prompt exploration, treatment of the underlying cause, and extensive surgical peritoneal lavage have always been the cornerstones of peritonitis therapy regimens (IOPL) 7,8 .Regular IOPL is performed to lessen bacterial contamination and burden.Even though large volumes of normal saline are used in IOPL, the rates of sepsis, wound infection, and mortality remain alarmingly high.Another method

MATERIAL AND METHODS
This was a retrospective Institution based study conducted between January 1, 2020, and September 31, 2021at Paediatric Surgical Unit of Holy family Hospital, Pakistan.The Ethical approval was received from Rawalpindi Medical University vide approval number MED-04-46-21.Pediatric subjects data included was from birth tillthe age of 12 years, managed and diagnosed for pediatric surgical conditions at Holy Family Hospital, Rawalpindi and admitted for surgical emergencies during the whole year of 2020.Pediatric surgical cases with multiple co-morbid who needed multidisciplinary management such as orthopedic,cardiac, ophthalmologic, neuro-surgical intervention, plastic, reconstructive services and were referred to proper specialized unit were excluded.Data collection procedure and instrument followed was registration records in the wards and operating rooms to pinpoint the target research populations.Following the retrieval of the patients' medical records, information was gathered from the chart using a standard, pre-structured template.Data entry and analysis: The acquired information was verified for accuracy, coded, entered into statistical software package (SPSS version 22), and then examined.Descriptive statistics of frequency and percentage were employed during the analysis, and the results were presented in tables.

RESULTS
A total of 898 patients under the age of 12 were operated in the operation theater during the 20 month study period.Out of the total operated patients, 65.4% of the patients were males, whereas the remaining 34.5% were females with 1 (0.1%) child having ambiguous gender.Most

DISCUSSION
When global health is discussed, the field of pediatric surgery has still to set a mark as a major subject 8 .In LMIC like ours, the Department of Pediatric Surgery have not been established except some major centers.The peripheries are devoid of trained pediatric surgeons and the attendants with limited resources resort to getting their child treated by a general surgeon available at the closest primary and secondary health care facility.Many a times pediatric surgical conditions are diagnosed at a later stage because of this very reason.Our institution is the only tertiary care center catering to Northern Punjab established in 2016, 69 years after the establishment of Holy Family hospital, Rawalpindi.This article summarizes the initial patient flow and cases operated during the period when the department was under development.A total of 898 patients were operated in the initial of development of the unit keeping in view that no separate elective and emergency operation theatre facility was specified.0][11][12][13] .The reason for male preponderance can't be fully elucidated.We stratified the patients into neonate <28days, then infant >28-2years of age, 2-8years of adult child.Majority of the patients 40% operated belonged to the age group 2-8years.This age group coincided with a study conducted in Nigeria where the mean age was calculated to be around 3 years of age.While other similar studies from Africa reported the main age to be around 4.9 -6.4 7,[9][10][11][12][13] .Disorders were categorized in the current study according to the main organ systems.The three main causes of paediatric surgery presentations at our facility were disorders of the gastrointestinal system, developmental anomalies, and disorders of the genitourinary system, with all three accounting for over 90% of all operations.Seconding the claim that "inguinal hernia repair is the most common operation performed by paediatric surgeons", surgery for inguinal hernias continues to be the most prevalent procedure 14 .15.1% of all surgeries were for inguinal hernias, which is in line with the 15.9%rate of paediatric surgical hospitalisations found by Alagoa and Gbobo in the Niger Delta of Nigeria 12 .Contrary to what some epidemiological studies claim, gastrointestinal abnormalities, both congenital and acquired diseases, appeared to be the most common cause of paediatric surgery in our centre 7,10,13 .4.8% of the procedures done in our institution were for trauma.The primary cause of this discrepancy could be attributed to the departments' exclusion of individuals who require neurosurgery and orthopaedic care.According to a research from Nigeria, 6.3% of all neonatal hospitalisations had congenital abnormalities (CAs) 15 and most research analysing the epidemiology of paediatric surgical hospitalisations have placed CAs in the top three 12 .We were not able to stratify our data into congenital and acquired causes as it was a retrospective study.Our data showed that gastrointestinal, genitourinary and patients with abnormalities related to head and neck region were the top three causes of pediatric surgical admission in our center.Temporal trends showed that the majority cases operated were around the month of October while the least cases operated were around the month of May and July.Reasons for decreased admission in both these months coincided with the months of Ramadan followed by Eid-ul-fitrin which the regular working hours are decreased by 1 light hour and the Hajj season, Eid-ul-Adha.Both these months have national public holidays for 4-5days approximatelyevery year.This study has summarized the temporal trends and spectrum of pediatric surgical problems operated in a recently developed unit.This study gives an overview of the burden department of pediatric surgery faces with limited human resources for a wide area of coverage.Department of Pediatric Surgery needs to be considered an essential part of all the health facility centers to reach the Sustainable Development Goals recognized by the United Nations.In order to improve child healthcare, initiatives ought to be taken to improve aspects such asmanpower, infrastructure, tools, anaesthesia, and pertinent research endeavours 16 .

CONCLUSION
The expected number of operated cases in a newly developed unit is comparable to other units that have been established for a long time.Therefore, in order to meet the demands of increasing number of pediatric surgical patients presenting to tertiary care hospitals, more well defined studies addressing these common ailments and the inclusion of paediatric surgery in public health initiatives covering primary and secondary health centers.

1: Distribution Of Age Group In Study Population Fig-2: Month Wise Load Of Patient Operated In Operation Theater The Demographics Of The Study Sample Demographic Variables
of the children (40%) going for surgery belonged to 2 years -8 years age group.11.2% belonged to <28 days age group, 31.7% to 28 days to 2 years age group, whereas 17% belonged to >8years age group.This is shown in Fig-1.42% surgeries were done due to causes related to gastrointestinal tract Fig-