Routine Pediatric Surgical Emergencies: Incidence, Morbidity, and Mortality During the 1st 8000 Days of Life—A Narrative Review

Typhoid fever is an infection caused by Salmonella typhi transmitted through the fecal–oral route, typically from contaminated food or poor water sanitation. Perforation due to typhoid fever or typhoid ileal perforation is a significant issue in LMICs and almost absent in HICs. The annual incidence of typhoid is estimated at 21 million cases, with an overall perforation rate of about 10% that increases with age, reaching a high of 30% by age 12 years [17]. Mortality ranges from 12% in surgically equipped facilities to 100% in areas without adequate surgical access [10, 14, 18, 19]. For those children who do survive, the majority experience one or more complications, including surgical site infections, dehiscence, and enterocutaneous fistulae causing significant morbidity [16, 18]. Typhoid fever can also cause other complications that may require surgery, including cholecystitis, osteomyelitis, and abscesses. Further work on this condition has emphasized the consequences of delayed diagnosis due to multifactorial causes and resource shortages in surgical systems. In addition, reviews have also emphasized the need for prevention of this condition through distribution of the typhoid vaccine and improved sanitation [20]. Routine vaccination against multi-drug resistant typhoid show promise in reducing disease burden globally, potentially averting 42.5 million cases [21]. Table 1 summarizes recent literature on typhoid intestinal perforation and expands on a prior scoping review.

Acute appendicitis is caused by inflammation of the appendix, typically due to bacterial build up in the appendiceal lumen obstructed by a fecalith, or less commonly by neoplasm or lymphadenopathy. The duration of inflammation is directly proportional to the severity and extent of the infection, meaning early diagnosis and treatment is paramount. Complicated or perforated appendicitis can often be avoided with timely treatment and surgical intervention. According to available data derived from mostly single-institution retrospective chart reviews from hospitals in the Gambia, Uganda, and Nigeria, appendicitis was the diagnosis for up to 17.1% of surgeries [6, 22, 23]. Reported mortality rate in LMICs can reach as high as 3.5% [24, 25]. Due to delays in presentation, complicated appendicitis is more common in LMICs, composing up 67–85% of all presenting appendicitis cases in some studies [14, 26]. Perforation rates range from 40 to 60% in LMICs [24, 27, 28]. Perforation may also lead to further complications such as abscesses, fistulas, and ultimately abdominal sepsis if left inadequately treated. Treatment of these complications are generally more invasive and may require bowel resection and multiple procedures, which portend a higher risk of surgical site infections and other postoperative complications. Table 2 summarizes characteristics of recent literature on abdominal emergencies in children in LMICs.

Intussusception is a condition in which one segment of intestine “telescopes” inside another, leading to intestinal obstruction. If not reduced in a timely fashion, swelling, inflammation, and ultimate perforation and abdominal sepsis ensues. Due to late presentation of intussusception in most African countries, the treatment has been mostly surgical [30]. Infants older than 4 weeks old and toddlers are most affected, but it may appear at any age. Intussusception is a leading cause of bowel obstruction and bowel resection in infants, however there is a paucity of demographic data in LMIC surrounding this condition [14]. The estimated annual incidence of childhood intussusception in Africa is 72 per 100,000 children, while reported cases in India, Vietnam, and China range from 2 to 54 per 100,000 to 200–800 per 100,000 per year. [30, 31]. However, these retrospective hospital-based studies probably underestimate the incidence of intussusception as they do not account for patients who may have died before reaching the hospital, presented to other facilities within the same region, or were treated with alternative diagnoses [30].

In Africa, the intestinal resection rates in patients presenting after more than 48 h ranged from 60 to 100% while for patients presenting within 48 h the corresponding value was 12.4% [30]. Some authors have used a 24 h cut-off to study outcomes; children who presented after 24 h of onset of symptoms had a higher incidence of bowel complications, a greater risk of failed operative reduction, and a higher chance of bowel resection at time of operation [14, 30]. At a teaching hospital in Ghana, more than 35% of children with intussusception underwent bowel resection for gangrenous bowel which was likely due to delayed presentation [14]. Late presentation leading to delayed surgery has also contributed to higher rates of post-operative complications such as septicemia, hemorrhage, and abscess formation [30].

Limited access to timely pediatric surgical and radiological expertise contributes to delay in diagnosis and surgical interventions [30]. In the absence of imaging such as ultrasound or plain film X-ray, definitive diagnosis can only be made using laparotomy [30, 32] Even without access to fluoroscope and/or ultrasound facilities, air enema reduction of intussusception can be attempted under anesthesia, with greater than 50% success rate if attempted early in the course of disease manifestation[17]. However, due to late presentation and lack of ultrasound or radiological services, especially outside normal work hours, pneumatic or hydrostatic reduction cannot be conducted, thus leaving surgical management as the only viable management option [30, 32]. This paradigm leads to a higher morbidity and mortality from intussusception in Africa than in other regions of the world [33]. Greater investment in rapid diagnosis, surgical services, and radiologic technology is needed to address this condition and reduce the likelihood of children undergoing bowel resection [30, 34].

Abdominal wall hernias are another common cause of intestinal obstruction in LMICs, as loops of intestine can become trapped, incarcerated, and subsequently strangulated within these abdominal wall defects.

Umbilical hernias are especially common in Africa. Umbilical hernias can occur in 91% of children 5 years or younger and 46% of children who are 10–15-year-old [35]. In the United States, umbilical hernias occur in 40–60% of infants and only 4% remain present after the age of 5, while the remaining spontaneously close [36]. In general, umbilical hernias should be repaired by 5 years of age if the defect does not obliterate spontaneously. In single center studies, incarceration from an umbilical hernia can occur in 37–44% of patients presenting to the hospital with symptoms [37, 38].

In Africa, inguinal hernias are present in 1–5% of children overall and in 35% of premature babies [17]. In the United States, the condition has a similar prevalence of 1–5% in children overall and a lower prevalence at 9–11% in premature infants [39]. Similar incidence rates exist in Asia, where inguinal hernias occur in 6.6% of males and 0.7% of females in a nationwide Taiwanese population study [40]. Given the heightened risk of incarceration, early elective herniotomy is the treatment of choice after diagnosis of a reducible inguinal hernia.

Elective herniotomy is usually a short outpatient case and is extremely cost-effective [41]. However, surgical backlog or compromised access to surgical care frequently prevents timely repair of these defects, which leads to a high incidence of incarcerated and strangulated hernias in LMICs [38, 42, 43]. In a Nigerian study, obstructed hernias made up 14.8% of all abdominal surgical emergencies, ranking third after typhoid ileal perforation and intussusception. Inadequate surgical capacity to accommodate elective cases prevents early surgical correction of this common condition, leading to preventable morbidity that necessitates emergent repair.

Septic arthritis is a joint infection that is caused by hematogenous or contiguous spread of bacteria, and sometimes due to direct inoculation. The incidence of septic arthritis is higher in younger children [47]. Due to the varied epidemiology that mimic acute bacterial septic arthritis such as tuberculosis or human immunodeficiency virus (HIV) associated arthropathy, across LMICs, it can be challenging to clinically distinguish a bacterial infection from other causes of an inflamed joint [48]. Moreover, the clinical presentation can manifest as less acute in immunocompromised children, such as those who are malnourished or HIV infected, and radiological changes are not apparent immediately. The invariable lack of access to microbiology services can lead to delayed diagnosis and resultant chronic infection, that in turn lead to physical limitations, chronic sinus formation and subsequent superinfection [49]. In addition, osteomyelitis can develop if the infection spreads into the adjacent bone.

Osteomyelitis is a bone infection that often results from direct inoculation into bone or contiguous or hematogenous spread of an infection from elsewhere in the body. Acute hematogenous osteomyelitis is the most common form of osteomyelitis in school age children but can happen at any age. It is often associated with the need for invasive diagnostic, surgical procedures, and prolonged course of antimicrobial treatment. [9, 50]. Furthermore, there is an association of osteomyelitis with sickle cell disease, which has a higher prevalence in LMICs [51]. Studies from LMICs show that patients with osteomyelitis may be older than most surgical patients on admission and experienced a significantly longer average length of stay [50, 52, 53]. Delayed and/or inadequate treatment of acute osteomyelitis in LMIC settings results in 60–80% of affected children presenting in the chronic phase [44, 54, 55], leading to more complex and multi-stage management [54]. Delayed treatment of open bone fractures can also contribute to osteomyelitis in up to a quarter of patients [56, 57]. One review demonstrated that early administration of antibiotics is the most important factor in prevention, but timely intervention does not consistently occur in LMICs [58]. Lack of imaging and microbiology also pose added challenges. A study estimates that 27% of patients with osteomyelitis require both multiple admissions and surgeries before treatment is successful [46]. In low-income countries, eradication of chronic osteomyelitis after treatment is never assured, and many patients have recurring infections and ultimately may require amputation of the affected limb [59].