The Leading Neonatal Surgical Conditions in Jose R.

Reyes Memorial Medical Center from January 1, 2000 to December 31, 2004
Marilyn Anastacio, M.D.; Spice Astorga, M.D.; Liezel Ballad, M.D.; Eileen Opena, M.D.; Aileen Sayo, M.D.; Rogelio Varela Jr. M.D.
Jose R. Reyes Memorial Medical Center Abstract A list of neonatal surgical patients was obtained within a 5 year period, from January 1, 2000 up to December 31, 2004. Medical records of the patients was then collected and reviewed. Researchers categorized the patients according to their mean age at the time of operation, sex distribution and body weight. A list of the 10 most common surgical conditions was then obtained from the data.

Objectives A. General Objective: To determine the prevalence of neonatal surgical conditions in Jose R Reyes Memorial Medical Center (JRRMMC) from January 1, 2000 to December 31, 2004, inclusive. B. Specific Objectives:

i. To provide baseline data on the occurrence of surgical cases among neonates admitted in JRRMMC from January 1, 2000 to December 31, 2004, inclusive. ii. To establish a list of the ten most common neonatal surgical conditions in JRRMMC from January 1, 2000 to December 31, 2004, inclusive. iii. To describe the neonates according to: birth weight, sex distribution, and mean age at the time of surgical intervention. iv. To determine the recovery rate and mortality rate of neonates undergoing surgery in JRRMMC from January 1, 2000 to December 31, 2004, inclusive. Significance of the Study Pediatric surgery, encompassing neonatal surgery, is 40% emergency work (15). This is because congenital abnormalities require immediate correction for compatibility with life and neonates have a different physiology compared to adults. In developed countries, better understanding of neonatal physiology and improvements in diagnostic facilities and

neonatal intensive care units (NICU) improved the outcome of neonatal surgery. In contrast, neonatal surgery in developing countries is problematic particularly in the emergency setting but, there are few reports from these countries (13). Literature search revealed that no data both from local registries and institutions are available for review and comparison for this type of study. Surgical problems in industrialized countries are technical in nature compared to the state of pediatric surgery in developing countries where the challenge lies on definition, policy making, and health care delivery (14). In line with these, the study aims to provide baseline record on three important aspects of neonatal surgery in a tertiary hospital of a developing country like the Philippines. Firstly, the statistics gathered will make available for further studies a clinical picture of the neonatal surgical conditions that commonly plague Filipino children and possibly contribute to evidence-based best practices for patients in the future. Second, the research will determine the recovery and mortality status of neonatal surgery in the said setting. These figures could give information on the level of institutional surgical expertise and on the state of diagnostic facilities and NICU in the sample tertiary hospital. Lastly, the data can be used to define and demonstrate that pediatric-surgical care (PSC) is a significant public health care problem requiring adequate health care policy to guarantee proper resource utilization especially for a developing country like the Philippines. After identifying the principal neonatal surgical conditions, a rational setting of priorities can be made. And eventually, cost-effective

interventions and efficient services can be provided. Background of the Study The British Association of Pediatric Surgeons (BAPS) defines specialist pediatric surgery in four clinical categories: a) Neonatal surgery, which involves the care of infants up to 44 weeks postconceptional age, b) Complex surgical conditions requiring special expertise such as oncology, hepatobiliary disease, major trauma, and the reconstruction of congenital abnormalities, c) Management of children with relatively straightforward surgical conditions who have associated disorders, and d) Pediatric urology(16). Neonatal surgery is an integral part of pediatric surgery because the transitional period following birth can be complicated by the presence of congenital anomalies requiring emergency surgical intervention. Neonatal surgery epitomizes the cooperation that must exist among the pediatrician, pediatric anesthesiologist, and pediatric surgeon to provide the foundation for a successful pediatric surgical team(20). Adequate amounts of literature from developed countries providing information on results of similar studies undertaken and on the current trends of pediatric surgery in their realm were found and reviewed. In Australia, a population-based descriptive study conducted in a two-year period noted that the prevalence of neonates undergoing surgery in New South Wales is 0.6%. The study advocates informing the parents of neonates requiring surgery of the level of institutional surgical expertise and involving them in the decision-making regarding the place of surgery for their infant (8). Similarly, a Canadian Neonatal Network collects clinical data prospectively on every admission to each of its 17 tertiary level units during a 22-month period. The purpose of this study done by Skarsgard et al was to interrogate the network database to determine case volumes, outcomes, and resource utilization for several neonatal surgical conditions. The neonatal surgical conditions identified were: spina bifida, congenital cystic lung disease, tracheoesophageal fistula, atresia/stenosis of small intestine, atresia/stenosis of large intestine/imperforate anus, Hirschsprung's disease, anomalies of the diaphragm, and anomalies of the abdominal wall (5). This study

aims to contribute to the determination of evidence-based best practices for prospective patients. In the last decade and a half, pediatric surgery in developed countries has been focused on fetal surgery and its improvement. This type of surgical intervention entails in utero correction of congenital abnormality such as prenatally diagnosed congenital diaphragmatic hernia. However, failure of most attempts at open surgical repair of the fetus for anomalies, the increased risk of premature labor, mixed results with other fetal procedures for anomalies such as the minimally invasive techniques of video fetoendoscopic and sonographic localization procedures, and the satisfactory results obtained from either in utero medical management or postdelivery surgical correction of anomalies led to sufficient decline in published papers on fetal surgery (24). More recently in pediatric surgery, there are shifts from open surgical repair to minimally invasive approaches to minimize trauma, approaches to address the fetal physiologic abnormality rather than the anatomic issue, and movement away from case reports and uncontrolled trials to multicenter, randomized controlled trials that can increase the clinical use of published pediatric surgery research results. In contrast to the situation in industrialized countries where many surgical problems are technical in character, the challenges for pediatric surgery in developing countries are those of definition, policy, and delivery (15). The recognition that the surgical needs of children differ from those of adults has led to remarkable improvements in care. Many children with congenital anomalies that were once thought incompatible with life are now living normally. Nevertheless, there are still major gaps in the surgical care of children living in developing countries. Pediatric surgery has often been viewed as too expensive and as a nonessential service, and it has been excluded from most child health programs in such countries (11). The most important issue surrounding the surgical care of children in developing countries is the burden of surgical diseases on pediatric populations (11). There is a lack of epidemiological data on this subject. In the Global Burden of Disease (GBD) study, it was found out that Group I diseases and conditions

are the traditional causes of disease burden in developing societies. These are communicable infections, maternal and perinatal conditions, and nutritional deficiencies and they represented 40% of the total global burden of disease in 1990. Only seven percent of the burden were accounted in developed countries compared to 49% found in developing regions. Congenital abnormalities are another common and underreported problem. Neonates with surgical problems are especially problematic, especially in emergency settings. Emergency neonatal surgery is attended by high morbidity and mortality in developing countries (14). In Africa, inguinal hernias, genitourinary and anorectal malformations, meningomyeloceles, and cleft lip and palate are the most common congenital anomalies (11). Health policy in developing countries cannot reflect the surgical needs of children until there are data demonstrating that pediatric surgical diseases are a significant public health problem. There is a major need for data on the epidemiology of pediatric surgical diseases, the morbidity and mortality associated with poor surgical care, and the cost of pediatric surgical services. Information on surgical diseases in developing countries can be expected to become increasingly important as evidence based methods are used to a greater extent in the allocation of resources. In the absence of data demonstrating that surgical diseases are a problem, it would be unreasonable to expect resources to be allocated for surgical care (11). Methodology I. Study Design

a.2. The neonatal surgical conditions considered in the study were patterned on the article by Skarsgard et al published in the Journal of Pediatric Surgery 2003; 38 and on the Pediatric Surgery chapters by Ibay, Jr et al and Engum et al in the Philippine Textbook of Surgery and Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice 16th Edition, respectively. Sample Size The lack of a sampling frame for simple random sampling of study population leads the investigators to use single-stage cluster sampling in choosing study subjects. All neonates admitted in the subject tertiary hospital requiring surgical intervention during the specified 60-month period were divided into clusters or sampling units. A total of four clusters were formed; each cluster is composed of the neonates belonging to one study year, that is, January 1, 2000 to December 31, 2000 comprises one sampling unit, January 1, 2001 to December 31, 2001 comprised another cluster, and so on. Each and everyone in these four sampling units were included in the study. III. a. Timing The medical records of neonates requiring surgical intervention from January 1, 2000 to December 31, 2004, inclusive, were reviewed starting on the third week of October 2004 to January 2005. b. Methods and Tools of Data Collection b.1. A letter asking permission to review the charts of the neonates requiring surgical intervention from January 1, 2000 to December 31, 2004, inclusive, was submitted to the Medical Records Officer. b.2. The investigators were grouped accordingly, first to systematically review the discharge analysis prepared by the medical records officer of the particular department. After having gathered the list of names of subjects, the medical charts were reviewed and the data needed for the study were collected. Data Collection

The study design used to determine the prevalence of neonatal surgical cases in JRRMMC is Cross-sectional Survey type of descriptive study. II. Selection of Subjects

Inclusion/Exclusion Criteria a.1. All neonates admitted in JRRMMC starting January 1, 2000 to December 31, 2004, inclusive, with congenital or acquired anomalies incompatible with life but amenable to surgical correction was included in the study.

b.3. The data gathered were encoded and analyzed using the Epi-Info software version 6.04. Significance of relationship of variables was assessed by evaluating the computed p value. b. Variables to be Investigated

The study primarily aims to determine the prevalence of neonatal surgical conditions in a tertiary hospital during a 60-month period and to establish the ten leading neonatal surgical conditions. Investigation of the profile of the subjects, such as sex distribution, birth weight, and mean age at the time of surgical intervention was made. The APGAR Score, New Ballard Score, and Disposition were also investigated to assess the recovery and mortality outcomes of surgical intervention done on the subjects. Limitation of the Study Data collection was cramped into three weeks due to time constraints. This was mainly subject to the flexibility of the schedule of the post graduate interns. The main source of data is the medical chart of the patients. The difficulty in acquiring the chart of the research subjects is directly proportional to its antiquity. It is highly probable that an old chart is buried in the record shelves or simply lost. Theoretical basis of this survey study were mostly acquired from western literatures and journals. There are no local scientific studies that may well support the entire survey study. Results and Discussion The study on the prevalence of neonatal surgical conditions covers a 60-month period from January 1, 2000 to December 31, 2004. During this time, JRRMMC had a total of _ neonatal admissions, of these there were 195 (%) cases of neonatal surgical cases noted.

80 60 40 20 0 2000 2001 2002 2003 2004

Fig. 1 Frequency Distribution of Neonates According to Year of Birth

The year with the highest number of neonatal surgical conditions was 67 (34.4%) during the year 2003. The lowest incidence of only 10 (5.1%) occurred, on the other hand, in the year 2002. There were 29 (14.9%) cases seen in 2000, 27 (13.8%) in 2001, and 62 (31.8%) last year 2004.

Female Male

Frequency by Gender

Fig.2 Frequency Distribution by Sex There were 131 (67.2%) female subjects and only 64 (32.8%) male subjects during the study period (See Fig 2). This is in contrast to what has been written in the literatures that the male population predominates in surgical conditions involving the neonates.

120 100 80 60 40 20 0
JRRMMC NID Other Hospital Lying-in

Figure 3. Frequency birthplace. In this study survey, a total of 52 cases (26.7%) were delivered in our institution. At about 31 cases though (15.9%) were delivered from other hospitals while 13 cases (6.7%) were delivered in a lying-in. On the other hand, 99 cases (50.8) were delivered at home either through midwives or quack doctors. This finding may significantly contribute to the incidence of the neonatal surgical patients seen during the 5-year study period. Poor assessment that leads to late diagnosis may promote a relatively poor prognosis. Top 10 Surgical Cases Imperforate anus (i.e. rectal atresia; rectal atresia with rectovaginal fistula) represents the most common neonatal surgical condition seen at Jose R. Reyes Memorial Medical Center with in the period from January 2000 up to December 2004. A total number of 90 patients out of 195 was noted (46.2%). This was followed by anomalies of abdominal wall (i.e. gastroschisis and omphalocoele) with a total of 25 patients (12.8%.) Atresia/Stenosis of the small intestine (i.e. duodenal atresia/stenosis; ileal atresia; duodenojejunal atresia; jejunal atresia; jejunoileal atresia) on the other hand ranked third with 22 patients out of 195 (11.5%) Ranking fourth are conditions that constitute Multiple Congenital Anomalies with 15 patients out of 195 (7.7%.) Spina bifida (i.e. lumbar meningocoele; sacrococcygeal meningocoele; scaromeningocoele; thoracolumbar meningocoele) ranked 5th in the list with a total of 10 patients (5.1%.) Cleft lip and palate represents the sixth most common neonatal surgical condition with 7 (3.6%) patients noted. This was followed by NEC with a total number of 6 patients (3.1%), diaphragmatic hernia with 5 patients (2.6%), Hirschprungs Disease with 4 patients (2.1%) and tracheoesophageal fistula with 3 patients (1.5%) respectively. RANK 1 2 Surgical Case Imperforate anus (with or without fistula) Anomalies of the abdominal wall Number of Patients 90 25 Percent 46.2% 12.8%

3 4 5 6 7 8 9 10

Atresia/Stenosis of Small Intestine Multiple Congenital Anomalies Spina Bifida Cleft lip and Palate NEC Diaphragmatic hernia Hirshprungs Disease Trancheoesophageal Fistula

22 15 10 7 6 5 4 3

11.5% 7.7% 5.1% 3.6% 3.1% 2.6% 2.1% 1.5%

Frequency of Disposition.
140 120 100 80 60 40 20 0 Discharged Died HAMA HPR

Frequency of surgical operations.

60 50 40 30 20 10 0 2000 2001 2002 2003 2004

Frequency of operated surgical condition that was discharged.

120 100 80 60 40 20 0 Discharged HAMA Series1 Series2

Frequency of operated conditions according to birth weight.

120 100 80 60 40 20 0 Discharged Died HAMA HPR

Summary and Conclusion

Recommendations Future studies investigating the prevalence of congenital anomalies like cardiac conditions and congenital hydrocephalus should be done to increase the awareness on the prevalence of these cases in tertiary hospitals in our country. Improvement in the computerization of the Medical Records Section of the hospital to improve the quantity and quality of data collected for research especially for retrospective studies. And if possible, a specific time allotment for postgraduate intern research should be implemented to ensure proper knowledge of research methods and data analysis. This could improve the attitude of those undertaking such activities, as not just another requirement but a worthwhile learning experience.

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