Pediatric Day Case Surgery in Rural Medical Outreach Programs: Enugu Experience

Background: Pediatric day case surgeries performed in the rural setting of medical outreach is of great benefit to the patients who could not have access to specialist pediatric surgical care. The purpose of study was to evaluate our experience in carrying out pediatric day case surgeries during medical outreaches in the rural settings of Enugu, south east Nigeria. Methods : This was a retrospective study of children that had day case surgeries during medical outreach in the rural areas of Enugu, south east Nigeria, over a 5-year period. The patients’ demographics, duration of symptoms, diagnosis, operative procedure performed, outcome of treatment and complications of treatment were evaluated. Results: During the study period, a total of 108 cases of pediatric day case surgeries were performed which accounted for 58.7% of all medical outreach surgeries. There were 81 (75%) males and 27 (25%) females, with a male to female ratio of 3:1. The median age of the patients was 54 months with a range of 10 – 72 months. The median duration of the lesions was 7 months. Herniotomy for inguinal hernia and hydrocele was the most common performed surgical procedure. All the surgeries were performed under general anesthesia. Outcome was good in most of the patients. Surgical site infection was the most common post-operative complication. There was no mortality. Conclusion: Pediatric surgical outreach programs offer opportunity for the treatment of surgical lesions of children in the rural areas who do not have access to specialist pediatric surgical care. Pediatric surgical outreach program can achieve reduction in surgical disease burden of children in the rural areas.


Introduction
Day case surgeries refer to elective procedures performed on the day of admission and the patient discharged home the same day. Other terms synonymous with day case surgery include ambulatory surgery, same day surgery, and outpatient surgery. In many countries of the world, there is a steady increase in the rates of day case surgery [1]. Healthcare providers, health policy makers and patients have appreciated the benefits of day case surgeries [1]. In developing countries, not all patients who need surgery can access it. The reasons for this can be summarized as 'barriers of surgery'. These barriers of surgery include physical, financial and low socio-economic status [2,3]. The inaccessibility to surgical treatment is worse in children due to paucity of trained pediatric surgeons and lack of specialist hospitals where surgical care can be offered especially in rural areas. Medical outreach, including surgeries, brings treatment to the domains of the children at no cost to the patients' caregivers such that the barriers of surgery are reduced, at least to an extent. Medical outreach forms an avenue for free dissemination of medical treatment to those who otherwise may not afford it. The purpose of study was to evaluate our experience in carrying out pediatric day case surgeries during medical outreaches in the rural settings of Enugu, south east Nigeria.

Patients and Methods
This was a retrospective study of children that had day

Preparatory Protocol
The community leaders and village heads were informed about the medical outreach program. The community heads in turn inform and mobilize members of the community. The venue for the outreach was the district/general hospitals located in the respective rural areas. There were pre-outreach visits, by the medical team, to the venue of the outreach in which local volunteers were educated on what their duties will be. There were also discussions and collaborations between medical team at the health centers and outreach medical team. The outreach team consisted of specialist pediatric surgeon, other medical specialists, resident doctors, anesthetists, nurses, pharmacists, medical students and other support staff. Drugs and sterile surgical instruments were provided by the visiting outreach team.

Outreach Day
On arrival at the venue, the villagers were already gathered.
Pre-operative evaluations were performed clinically and informed consent obtained. Pre-operative investigations were not done. The surgeries were performed by resident doctors and a consultant pediatric surgeon. The anesthesia was conducted by doctor anesthetist. All the surgeries were performed under general anesthesia.

Post-Operative Management
Post-operative care was handled by the medical personnel's resident at the rural areas. This basically involves removal of wound dressing and wound dressing. Analgesics and antibiotics were given for 5 days. Communications were maintained with local health personnel.

Data Collection
The following data were collected: Gender, age, duration of symptoms, diagnosis, operative procedure performed, outcome of treatment and complications of treatment.

Data Analysis
IBM Statistical Package for Social Science (SPSS) for windows version 23 (IBM Corp., Armonk, NY) was used for data entry and analysis. Data were expressed as percentages and medians.

Ethics Approval
This was not an institutional based study. The need for ethical clearance does not arise.

Patient's Demography
During the period of the study, a total of 184 surgeries were performed at the outreach programs, out of which 108 cases (58.7%) were pediatric day case surgeries. There were 81 (75%) males and 27 (25%) females, with a male to female ratio of 3:1.
Details are depicted in (Table 1).

Patient's Diagnosis
Diagnosis of the patients is shown in (Table 2).

Outcome and Post-Operative Complications
Ninety eight (90.7%) patients had uneventful recovery. Six surgery [6]. In children, the benefits of day case surgery are clear and this has spread to other specialties [6]. However, in urological surgeries, more adults may participate in day care surgeries [7]. In the present study, more males were operated on than female. This finding is consistent with the report of other studies on pediatric day cases [8,9]. The median age of our patients are in line with the findings of similar studies [9,10], while it varies with the report of other studies [11,12]. of the medical outreach may also affect the complexity of surgeries that can be performed. In the present study, only day cases were performed because the outreach program lasted for only one day in each centre. Herniotomy was the most common performed surgical procedure. This is in agreement with the report of other researchers [11,13]. Other procedures performed include orchidopexy for undescended testis and excision of masses. This is similar to the findings of other studies [8,11]. Procedures such as Sistrunk operations, circumcisions, release of tongue tie and syndactyly could also be performed as day cases [8,10]. The overall outcome of the outreach programs was good. Majority of the patients did

Conclusion
Pediatric day case surgeries performed during outreach programs is of immense benefit to people in the rural communities.
Although the operating environment is suboptimal, more of such outreaches will offer specialist care services to children in the rural area who otherwise could not afford such services. Pediatric surgical outreach program can achieve reduction in surgical disease burden of children in the rural areas.