Epidemiology of paediatric surgical admissions to a government referral hospital in the Gambia.

Epidemiology of paediatric surgical admissions to a government referral hospital in the Gambia Stephen W. Bickler1, 2 & Boto Sanno-Duanda1 Introduction There is a paucity of published data on the type of conditions that require surgery among children in sub-Saharan Africa. Such information is necessary for assessing the impact of such conditions on child health and for setting priorities to improve paediatric surgical care. Methods Described in the article is a 29-month prospective study of all children aged <15 years who were admitted to a government referral hospital in the Gambia from January 1996 to May 1998. Results A total of 1726 children were admitted with surgical problems. Surgical patients accounted for 11.3% of paediatric admissions and 34 625 total inpatient days. The most common admission diagnoses were injuries (46.9%), congenital anomalies (24.3%), and infections requiring surgery (14.5%). The diagnoses that accounted for the greatest number of inpatient days were burns (18.8%), osteomyelitis (15.4%), fractures (12.7%), soft tissue injuries (3.9%), and head injuries (3.4%). Gambian children were rarely admitted for appendicitis and never admitted for hypertrophic pyloric stenosis. The leading causes of surgical deaths were burns, congenital anomalies, and injuries other than burns. Discussion Prevention of childhood injuries and better trauma management, especially at the primary and secondary health care levels, should be the priorities for improving paediatric surgical care in sub-Saharan Africa. Surgical care of children should be considered an essential component of child health programmes in developing countries. Keywords: surgery; child, hospitalized; referral and consultation; hospitals, public; prospective studies; Gambia. Bulletin of the World Health Organization, 2000, 78: 1330–1336. Voir page 1335 le re´sume´ en franc¸ais. En la pa´gina 1335 figura un resumen en espan˜ol. Introduction Hospital admission data can be a valuable tool for assessing the epidemiology of diseases within populations. With a minimum amount of data collection, substantial insight can be had into the types of diseases, the age at which conditions present, and their burden on inpatient service. And although these data are inevitably referral- and access-biased, they can provide useful information on morbidity in the community (1). Little is known about the surgical diseases that affect children living in sub-Saharan Africa. Data are lacking on the spectrum of surgical conditions, the mortality and morbidity associated with lack of surgical services, and the burden of paediatric surgical diseases on the health systems. Incomplete informa- tion has made it difficult to define an appropriate role for paediatric surgery in Africa, and to assess the impact of surgical diseases on child health. We describe the clinical epidemiology of paediatric surgical admissions to the Royal Victoria Hospital (RVH) in Banjul, the Gambia. Materials and methods Background The Gambia (population, 1.04 million; total land area, 10 689 km2) is situated in West Africa and is surrounded on three sides by Senegal and on the west by the Atlantic Ocean. In 1997, the country was among the least developed in the world, ranking 165 out of 168 on the Human Development Scale (2). The estimated per capita income is US$ 302 per year. The infant and under-five mortality rates are 85 and 137 per 1000, respectively (3). The population growth rate in 1993 was 4.2%. The RVH in Banjul is the national referral hospital. The 150-bed RVH paediatric unit is located adjacent to the main hospital and the children’s surgical ward has 35 beds. Data collection The records of all children admitted to the children’s surgical ward between January 1996 and May 1998 were reviewed by S.W.B. For each admission the patient’s name, medical record number, age, sex, primary diagnosis, dates of admission and discharge, procedures, and outcome were recorded. Results From January 1996 through May 1998, a total of 1655 children were admitted to the children’s 1 Department of Surgery, Royal Victoria Hospital, Banjul, The Gambia. 2 Assistant Clinical Professor, Division of Pediatric Surgery, UCSD Medical Center, 200 West Arbor Drive, San Diego, CA 92103-8401, USA (email: Sbickler@ucsd.edu). Correspondence should be addressed to this author. Ref. No. 99-0319 Research 1330 # World Health Organization 2000 Bulletin of the World Health Organization, 2000, 78 (11) surgical ward at the RVH. This cohort of children accounted for 1726 admissions and 34 625 total hospital days. The readmission rate was 4.3%. A total of 58 children were admitted twice, 11 children three times, and 2 children four times. The average inpatient census was 40 patients, corresponding to a bed occupancy rate of 114%. The clinical base during the study included 6630 paediatric surgery outpatient visits, 15 236 paediatric medicine admis- sions, and 25 856 paediatric medicine outpatient visits. Surgical patients accounted for 11.3% of paediatric admissions. The age distribution of paediatric surgical admissions is shown in Fig 1. The average patient age was 5.2 years (95% confidence interval (CI) = 5.0–5.4). A total of 51%of the childrenwere <5 years old, and 13% were aged less than 1 year. The male to female ratio was 1.9:1. The epidemiological features of paediatric surgical admissions are summarized in Table 1. The 58 diagnoses are grouped into nine major categories. The most common diagnostic categories were injuries (46.9%), congenital anomalies (24.3%), and surgical infections (14.5%). The most common injuries were burns (18.1%), fractures (9.8%), and head injuries (7.6%). Seasonal variations were noted for burns and head injures (Fig. 2). Burns were most common during the cool months of the year (December–February). The peak incidence of head injuries coincided with the mango harvest when children climbed trees to collect the fruit (April–May). A second peak in head injuries was noted in December–January when children climbed trees to collect firewood. The most common congenital anomalies were inguinal hernias and hydroceles (9.6%), cleft lips and palates (2.0%), anorectal anomalies (1.7%), and Hirschsprung’s disease (1.2%). The average age of children admitted for treatment of congenital anomalies was 3.9 years (95% CI = 3.5–4.2). A total of 75% of children admitted for congenital anomalies were aged >1 year. The most common infections requiring surgi- cal intervention were osteomyletis (5.7%), abscesses (4.2%), and pyomyositis (1.4%). All children with osteomyletis had advanced disease and were ad- mitted for sequestrectomy. Children with abscess and pyomyositis were admitted when they required wound care that could not be provided in an outpatient setting. The diagnoses that accounted for the greatest number of hospital days are shown in Table 2. The following single diagnoses were responsible for the largest number of hospital days: burns (18.8%), osteomyelitis (15.4%), fractures (12.7%), soft tissue injuries (3.9%), and head injuries (3.4%). All types of injuries accounted for almost 50% of the total inpatient days. Two of the most common paediatric surgical conditions in industrialized countries were rare or absent in the Gambia: only 16 children were treated for appendicitis, making it the 23rd most common admission diagnosis; and there were no admissions for hypertrophic pyloric stenosis. A total of 89 children with surgical conditions died while in the hospital, giving an overall mortality rate of 5.3%. The distribution of paediatric surgical deaths was as follows: burns accounted for 36% of surgical deaths, congenital anomalies for 24%, trauma for 12%, infection for 11%, and other causes for 17%. The highest case-specific mortality rates occurred for selected congenital anomalies. Among the most common conditions, the highest mortality rates were found among children with meningo- myelocele (42%) and posterior urethral valves (40%). Discussion The results of this study provide valuable insight into the surgical conditions that affect children living in sub-Saharan Africa. Our data include the spectrum of common paediatric surgical conditions, the associated morbidity and mortality, and the burden of these conditions on the health services. Other epidemiolo- gical features provide clues as to how paediatric surgery might be improved in sub-Saharan Africa. A wide spectrum of surgical conditions affect African children. The majority of patients, however, fall into three major diagnostic categories — injuries, congenital anomalies, and surgical infections. In our series, these three diagnostic categories accounted for almost 90% of paediatric surgical admissions. Injuries were responsible for the largest number of admissions (46.9%), the greatest number of inpatient days (49.1%), and were the leading cause of surgical deaths (48%). The most common injury diagnosis was burns (18.1%), followed by fractures (9.8%) and head injuries (7.6%). As a single diagnosis, burns were responsible for the greatest number of hospital days (18.8%) and were the leading cause of surgical deaths (36%). Several diagnoses within the injury category were directly related to poor surgical care. A total of 29 children were treated for burn contractures, a preventable complication when burns over joints are 1331Bulletin of the World Health Organization, 2000, 78 (11) Epidemiology of paediatric surgical admissions in the Gambia Table 1. Epidemiological features of the most common paediatric surgical admissions, Royal Victoria Hospital, Banjul, the Gambia, January 1996 to May 1998 Diagnosis No. of admissions Average age Age range M (n) F (n) M:F (years) (years) Trauma and burns Burn 313 (18.1)a 3.4; 3.1–3.7 b 0.1–14 182 131 1.4 Fracture 169 (9.8) 6.8; 6.3–7.3 0–14 98 71 1.4 Head injury 131 (7.6) 6.7; 6.1–7.3 0.3–15 88 43 2.0 Soft tissue injury 76 (4.4) 6.5; 5.8–7.2 0.1–13 51 25 2.0 Burn contracture 29 (1.7) 6.3; 5.1–7.5 2–12 11 18 0.6 Laceration 28 (1.6) 5.5; 4.1–6.9 0–13 19 9 2.1 Abdominal trauma 20 (1.2) 7.9; 6.6–9.2 2–13 19 1 19.0 Wound problem 14 (0.8) 4.8; 3.0–6.6 0.8–12 9 5 1.8 Dislocation 8 (0.5) 7.4; 5.6–9.2 4–11 7 1 7.0 Postfracture extremity necrosis 8 (0.5) 8.2; 7.2–9.2 5–9.5 5 3 1.7 Snake bite 6 (0.3) 12.2; 11.4–13.0 11–14 5 1 5.0 Other 7 (0.4) 5.6; 2.9–8.3 1.6–10 4 3 1.3 Subtotal 809 (46.9) 5.4; 5.2–5.6 0–15 498 311 1.6 Congenital anomalies Inguinal hernia 165 (9.6) 4.3; 3.9–4.7 0–13 162 3 54.0 Cleft lip/palate 34 (2.0) 2.0; 1.1–2.9 0.3–13 12 22 0.5 Anorectal anomaly 30 (1.7) 3.3; 1.9–4.7 0–11 21 9 2.3 Hirschsprung’s disease 21 (1.2) 3.7; 2.5–4.9 0–9 18 3 6.0 Undescended testicle 20 (1.2) 6.6; 5.0–8.2 2–14 20 0 – Club foot 19 (1.1) 1.8; 1.3–2.3 0.1–4 12 7 1.7 Meningomyelocele 19 (1.1) 0.3; 0.1–0.5 0–1.5 6 13 0.5 Umbilical hernia 17 (1.0) 2.9; 1.4–4.4 0.1–10 9 8 1.1 Hypospadius 11 (0.6) 4.9; 3.4–6.4 1.3–10 11 0 – Posterior urethral valves 10 (0.6) 2.5; 0.4–4.6 0–10 8 2 4.0 Bladder extrophy 9 (0.5) 2.9; 1.3–4.5 0.8–8 4 5 0.8 Omphalocele 9 (0.5) 4.5; 1.3–7.7 1–8 6 3 2.0 Cystic hygroma 7 (0.4) 3.1; 1.5–4.7 1–7 4 3 1.3 Other 49 (2.8) 4.6; 3.5–5.7 0–14 22 27 0.8 Subtotal 420 (24.3) 3.9; 3.5–4.2 0–14 315 105 3.0 Surgical infections Osteomyelitis 98 (5.7) 7.8; 7.0–8.6 0.1–14 59 39 1.5 Abscess 73 (4.2) 4.2; 3.3–5.1 0–13 48 25 1.9 Pyomyositis 25 (1.4) 6.8; 5.5–8.1 1.3–14 21 4 5.3 Cellulitis 16 (0.9) 4.5; 2.1–6.9 0–14 10 6 1.7 Hand infection 8 (0.5) 4.5; 2.4–6.6 1.2–10 6 2 3.0 Tuberculosis 8 (0.5) 6.3; 3.9–8.7 2–11 5 3 1.7 Septic arthritis 5 (0.3) 8.0; 4.4–11.6 2.8–13 4 1 4.0 Other 17 (1.0) 7.2; 4.5–9.9 0.1–14 11 6 1.8 Subtotal 250 (14.5) 6.2; 5.7–6.8 0–14 164 86 1.9 Gastrointestinal Foreign body in the oesophagus 21 (1.2) 4.9; 3.5–6.3 0.5–13 14 7 2.0 Appendicitis 16 (0.9) 12.1; 11.4–12.8 10–14 7 9 0.8 Abdominal pain 13 (0.8) 7.3; 4.9–9.7 0.3–14 11 2 5.5 Small bowel obstruction 8 (0.5) 3.4; 0.1–6.7 0.1–11 3 5 0.6 Caustic ingestion 6 (0.3) 4.3; 1.7–6.9 1–9 5 1 5.0 Intussusception 5 (0.3) 2.0; 0–4.0 0.7–6 4 1 4.0 Rectal prolapse 5 (0.3) 3.6; 1.3–5.9 1.3–8 1 4 0.3 Other 25 (1.4) 4.2; 2.7–5.6 0.8–12 18 7 2.6 Subtotal 99 (5.7) 5.9; 5.0–6.8 0.1–14 63 36 1.8 1332 Bulletin of the World Health Organization, 2000, 78 (11) Research grafted early and splinted. Extremity amputations for necrotic limbs, resulting from fracture mismanage- ment by traditional healers, were performed on 8 children. Unreduced fractures and dislocations were also commonly seen. Joint functionwas rarely restored when children presented late with dislocations. The common problem of paediatric trauma has been described at other centres in Africa. In Dar-es- Salaam, the United Republic of Tanzania, for example, injuries were the leading cause of death and accounted for almost half of all paediatric surgical admissions (4). In Lilongwe, Malawi, 9.7% of all paediatric admissions were related to accidents: 27% of cases were burns and scalds, and 32% were fractures usually caused by falls (5). A household survey suggested that 21% of urban children and 15% of rural children would suffer an accidental injury each year and that half would visit health centres. In South Africa, trauma is the leading cause of death among children aged >5 years (6). These reports support our contention that injuries are a significant public health threat to African children. Congenital anomalies (24.3%) were the second most common diagnostic category, with the most striking feature of this group of children being their delayed presentation. In our series, the average age of children admitted for treatment of a congenital anomaly was 3.9 years (95% CI = 3.5–4.2). Of the children admitted with congenital anomalies, 75% were aged >1 year. While it was our practice to delay surgery for some congenital anomalies to minimize risks associated with anaesthesia (e.g. cleft lip repair at 6 months of age), in most instances delayed presenta- tionmade repair more difficult. Likemany countries in sub-Saharan Africa, the Gambia does not routinely screennewborns for congenital anomalies. Thepattern of congenital anomalies in our series was similar to that reported from other regions of Africa (7, 8). Surgical infections (14.5%) were the third most common diagnostic category. Within this category, chronic osteomyelitis was the dominant problem. Osteomyelitis accounted for 5.7% of total admis- sions, and 15.4% of total inpatient days. Osteo- myelitis was second only to burns in terms of the total number of hospital days. Our data illustrate the serious problem osteomyelitis poses for children living in sub-Saharan Africa, and the large burden this condition places on health services. We believe the relatively few admissions for appendicitis and the absence of pyloric stenosis in our series reflect true differences in the incidences of these conditions in the Gambia. Although it is possible that Table 1 (continued) Diagnosis No. of admissions Average age Age range M (n) F (n) M:F (years) (years) Urology Paraphimosis 11 (0.6) 6.5; 4.8–8.2 2.3–11 11 0 – Urethrocutaneous fistula 6 (0.3) 8.2; 5.6–10.8 3–13 6 0 – Bladder stone 5 (0.3) 3.8; 1.9–5.7 2–7 4 1 4.0 Urinary retention 5 (0.3) 8.9; 4.4–13.4 1.4–13 5 0 – Other 15 (0.9) 5.0; 2.7–7.3 0.1–13 14 1 14.0 Subtotal 42 (2.4) 6.1; 4.9–7.3 0.1–13 40 2 20.0 Neoplasms Malignant 19 (1.1) 7.2; 5.4–9.0 1.8–13 9 10 0.9 Benign 17 (1.0) 7.5; 5.5–9.5 0.3–14 6 11 0.5 Subtotal 36 (2.1) 7.4; 6.0–8.7 0.3–14 15 21 0.7 Ear, nose, and throat Airway obstruction 9 (0.5) 3.2; 1.5–4.9 0.2–9 5 4 1.2 Cancrum oris 8 (0.5) 3.0; 2.1–3.9 0.7–4.8 1 7 0.1 Other 12 (0.7) 5.3; 4.1–6.4 3–8 8 4 2 Subtotal 29 (1.7) 3.9; 3.1–4.7 0.25–9 14 15 0.9 Neurosurgical Hydrocephalus 15 (0.9) 1.8; 0.3–3.3 0.1–10 7 8 0.9 Encephalocele 5 (0.3) 8.4; 2.9–13.9 1–13 4 1 4.0 Other 3 (0.2) 5.4; 0.4–10.4 1.2–10 2 1 2.0 Subtotal 23 (1.3) 3.8; 1.8–5.7 0.1–13 13 10 1.3 Miscellaneous Orthopaedic 6 (0.3) 5.8; 3.2–8.4 2–11 5 1 5.0 Thyroid 3 (0.2) 13.0; 13.0–13.0 13–13 0 3 0.0 Other 9 (0.5) 5.2; 3.4–7.0 1.4–10 4 5 0.8 Subtotal 18 (1.0) 6.7; 4.9–8.5 1.42–13 9 9 1.0 Total 1726 (100.0) 5.2; 5.0–5.4 0–15 1131 595 1.9 a Figures in parentheses are percentages. b Figures in italics are 95% confidence intervals. 1333Bulletin of the World Health Organization, 2000, 78 (11) Epidemiology of paediatric surgical admissions in the Gambia some children with these conditions die before arriving at the hospital, the large clinical base during the study makes this unlikely. The presence of Western-trained paediatricians and surgeons at RVH who are familiar with the diagnosis of these conditions makes misdiagnosis also unlikely. Moreover, in our series appendicitis was the 23rd most common diagnosis on admission. It seems unlikely that children would seek treatment for all other surgical conditions, yet not seek care for appendicitis. Using admissions data from the RVH, we have estimated the annual incidence of childhood appendicitis in the Gambia to be 0.6 per 10 000 children aged <14 years — 1/30th the incidence among Caucasian children in industria- lized countries (9). Recently, we suggested that geographical variation in common paediatric surgical conditions may provide clues to the etiology of a number of noncommunicable diseases (10). The results of the present study should be helpful in setting priorities for improving paediatric surgical care in sub-Saharan Africa. Our data show clearly that injuries are the most serious surgical problem affecting African children, accounting for the largest number of admissions, the greatest number of hospital days, as well as being the leading cause of surgical deaths. Based on these findings, prevention of childhood injuries and better trauma management should be the priorities for improving paediatric surgical care in Africa. Injury prevention would seem to be the most cost-effective method of addressing the problem of paediatric trauma. Injury prevention has been very successful in industrialized countries — reducing the incidence of some childhood injuries by as much as 50% (11). Strategies for preventing childhood injuries in developing countries have been reviewed by Mohan (12). We agree with Forjuoh et al. (13) that African governments must assume the central role in this respect. Because trauma prevention programmes will not completely eliminate childhood injuries, improv- ing the care of injured childrenmust also be a priority. Our data suggest a clear need to improve injury management at the primary and secondary health care levels. Basic trauma care at these levels is essential if the morbidity and mortality associated with late presentation is to be avoided. This strategy would also ease the burden on referral hospitals in sub-Saharan Africa, which are currently over- whelmed with relatively minor surgical conditions. Finally, our study suggests that paediatric surgical conditions are common in sub-Saharan Africa. In our series, children with such conditions accounted for 11.3% of paediatric admissions and almost 20% of paediatric outpatient visits. Our experiences have also shown us that there is significant mortality and morbidity associated with poor surgical care. Paediatric surgical care should be considered an essential component of child health programmes in developing populations. n Acknowledgements We thank the many colleagues at the RVH who contributed to the collection of data on which this study is based. Support from a Denis Burkitt Fellowship, Royal Society of Tropical Medicine, London, England, is also gratefully acknowledged. Table 2. Paediatric surgical conditions responsible for the greatest number of inpatient days, Royal Victoria Hospital, January 1996 to May 1998 Diagnosis Total hospital days % of total Burn 6498 18.8 Osteomyelitis 5322 15.4 Fracture 4390 12.7 Soft tissue injury 1365 3.9 Head injury 1175 3.4 Burn contracture 1058 3.1 Inguinal hernia 1015 2.9 Abscess 813 2.3 Wound problem 681 2.0 Hydrocephalus 611 1.8 Hirschsprung’s disease 550 1.6 Anorectal anomaly 543 1.6 Cleft lip/palate 512 1.5 Cancrum oris 437 1.3 Snake bite 433 1.3 Meningomyelocele 409 1.2 Bladder extrophy 384 1.1 Laceration 381 1.1 Tumour 379 1.1 Pyomyositis 364 1.1 Other 7305 21.1 Total 34 625 100.0 1334 Bulletin of the World Health Organization, 2000, 78 (11) Research Re´sume´ Epide´miologie des admissions en chirurgie pe´diatrique dans un hoˆpital public de recours en Gambie Pour les enfants vivant en Afrique subsaharienne, nous manquonsdedonne´esdans lesdomainessuivants : spectre des affections chirurgicales, mortalite´ et morbidite´ associe´es a` l’absence de services de chirurgie, charge des affections chirurgicales pe´diatriques sur les syste`mes de sante´. Il est de ce fait difficile de de´finir un roˆle approprie´ pour la chirurgie pe´diatrique en Afrique et d’e´valuer l’impactdesaffections chirurgicales sur la sante´ de l’enfant. Afin de mieux de´finir l’e´pide´miologie des affec- tions chirurgicales pe´diatriques en Afrique subsaha- rienne, nous avons re´alise´ une e´tude prospective sur tous les enfants de moins de 15 ans admis dans un hoˆpital public de recours en Gambie entre janvier 1996 et mai 1998. Au total, 1726 enfants ont e´te´ hospitalise´s pour des proble`mes ne´cessitant une intervention chirurgicale, ce qui repre´sente 11,3 % des admissions pe´diatriques et 34 625 jours d’hospitalisation. Les enfants africains sont touche´s par de nombreuses affections chirurgicales, mais la plupart des cas appartiennent a` trois grandes cate´gories – les traumatismes, les anomalies conge´nitales et les infec- tions. Dans la se´rie e´tudie´e, ces trois cate´gories diagnostiques repre´sentaient pre`s de 90 % des hospi- talisations en chirurgie pe´diatrique. Les traumatismes e´taient a` l’origine du plus grand nombre d’admissions (46,9 %) et de jours d’hospitalisa- tion (49,1 %), et ils e´taient la cause majeure des de´ce`s chirurgicaux (48 %). Les bruˆlures constituaient le diag- nostic le plus fre´quent (18,1 %) ; elles e´taient suivies par les fractures (9,8 %) et les traumatismes craˆniens (7,6 %). Les bruˆlures en tant que cause unique de traumatisme e´taient a` l’origine du plus grand nombre de jours d’hospitalisation (18,8 %) et de de´ce`s chirurgicaux (36 %). Elles e´taient surtout fre´quentes pendant la saison fraıˆche, alors que les traumatismes craˆniens survenaient plus fre´quemment a` la saison des mangues, lorsque les enfants grimpent aux arbres pour cueillir les fruits. Les anomalies conge´nitales (24,3 %) repre´sentaient par leur fre´quence la deuxie`me cate´gorie diagnostique. La caracte´ristique la plus frappante dans ce groupe d’enfants e´tait la consultation tardive. L’aˆge moyen des enfants hospitalise´s pouruneanomalie conge´nitale e´tait de3,9ans (intervalle de confiance a` 95 % : 3,5–4,2), et 70 % d’entre eux avaient plus d’un an a` l’admission. Comme la plupart des pays d’Afrique subsaharienne, la Gambie ne proce`de pas au de´pistage syste´matique des anomalies conge´nitales chez les nouveau-ne´s. La troisie`me cate´gorie de diagnostic par sa fre´quence e´tait constitue´e par les infections chirurgicales (14,5 %), avec au premier plan les oste´omye´lites chroniques. L’oste´omye´lite e´tait a` l’origine de 5,7 % de l’ensemble des admissions et 15,4 % des jours d’hospi- talisation, et venait juste apre`s les bruˆlures pour le nombre total de jours d’hospitalisation. Nos donne´es illustrent la gravite´ du proble`me de l’oste´omye´lite chez les enfants africains et le lourd fardeau que cette affection fait peser sur les services de sante´. Les enfants gambiens e´taient rarement hospitalise´s pour une appendicite et jamais pour une ste´nose hypertrophique du pylore, deux des affections chirurgica- les pe´diatriques les plus courantes dans les pays industrialise´s. L’appendicite venait au 24e rang des diagnostics a` l’admission chez les enfants e´tudie´s. Nous pensons que le nombre relativement faible d’hospitalisa- tions pour appendicite et l’absence de ste´nose pylorique dans notre se´rie refle`tent des diffe´rences re´elles d’inci- dence de ces maladies dans la population gambienne. D’apre`s nos donne´es, l’ame´lioration des soins de chirurgie pe´diatrique en Afrique subsaharienne devrait passer en priorite´ par la pre´vention des traumatismes chez l’enfant et par leur meilleure prise en charge. La pre´vention des traumatismes a e´te´ une re´ussite incontestable dans les pays industrialise´s, et serait probablement la strate´gie ayant le meilleur rapport couˆt- efficacite´ en Afrique subsaharienne e´galement. Comme les programmes de pre´vention n’e´limine- ront pas entie`rement les traumatismes chez l’enfant, il faudra e´galement accorder la priorite´ a` l’ame´lioration des soins aux enfants qui en sont victimes. Nos donne´es montrent qu’il serait ne´cessaire d’ame´liorer la prise en charge des traumatismes aux niveaux primaire et secondaire des soins de sante´. Il est indispensable d’assurer le traitement de base des traumatismes a` ces niveaux si l’on veut e´viter la morbidite´ et la mortalite´ associe´es a` une consultation tardive. Cette strate´gie e´viterait aussi d’accroıˆtre la charge des hoˆpitaux de recours, de´ja` de´borde´s par le traitement d’affections chirurgicales relativement mineures. Resumen Epidemiologı´a de los ingresos de cirugı´a pedia´trica en un hospital de derivacio´n pu´blico en Gambia Los datos de que disponemos sobre la poblacio´n infantil del A´frica subsahariana son insuficientes en lo que respecta al espectro de afecciones quiru´rgicas, la mortalidad y la morbilidad asociadas a la falta de servicios quiru´rgicos, y la carga que suponen las enfermedades pedia´tricas de cara´cter quiru´rgico para los sistemas de salud. Esa insuficiente informacio´n ha dificultado la tarea de definir un papel apropiado para la cirugı´a pedia´trica en A´frica, ası´ como la evaluacio´n de la repercusio´n en la salud infantil de las enfermedades que requieren cirugı´a. A fin de caracterizar mejor la epidemiologı´a de las enfermedades pedia´tricas que requieren cirugı´a en el A´frica subsahariana, procedimos a estudiar retrospecti- vamente a todos los nin˜os menores de 15 an˜os que habı´an sido ingresados en un hospital de derivacio´n 1335Bulletin of the World Health Organization, 2000, 78 (11) Epidemiology of paediatric surgical admissions in the Gambia pu´blico en Gambia durante el periodo de enero de 1996 a mayo de 1998. En total habı´an sido ingresados 1726 nin˜os con problemas quiru´rgicos, lo que repre- sentaba el 11,3% de los ingresos de pediatrı´a y un total de 34 625 dı´as de hospitalizacio´n. Los nin˜os africanos se ven afectados por un amplio espectro de enfermedades que requieren atencio´n quiru´rgica. La mayorı´a de los pacientes, sin embargo, pueden clasificarse en tres categorı´as diagno´sticas principales: traumatismos, anomalı´as conge´nitas, e infecciones quiru´rgicas. En nuestra serie, estas tres categorı´as diagno´sticas representaban casi el 90% de los ingresos de cirugı´a pedia´trica. Los traumatismos son la principal causa de ingreso (46,9%), ocasionan el mayor nu´mero de dı´as de hospitalizacio´n (49,1%), y son asimismo la primera causa de defuncio´n quiru´rgica (48%). El diagno´stico ma´s frecuente de traumatismo fueron las quemaduras (18,1%), seguidas de las fracturas (9,8%) y los traumatismos craneales (7,6%). Considerando los casos con un solo diagno´stico, las quemaduras fueron la causa del mayor nu´mero de dı´as de hospitalizacio´n (18,8%) y la causa principal de defuncio´n quiru´rgica (36%). Las quemaduras eran ma´s frecuentes durante la estacio´n frı´a, y los traumatismos craneales se daban con mayor frecuencia durante la temporada de recolecta del mango, en la que participan muchos nin˜os trepando a los a´rboles. Las anomalı´as conge´nitas (24,3%) fueron la segunda categorı´a diagno´stica ma´s frecuente. El dato ma´s llamativo sobre este grupo de nin˜os es la tardanza con que los llevaron al hospital. La edad promedio de los nin˜os con tales anomalı´as fue de 3,9 an˜os (intervalo de confianza del 95%: 3,5-4,2). En total un 70% de los nin˜os ingresados con anomalı´as conge´nitas superaban el an˜o de edad. Al igual que la mayorı´a de los paı´ses del A´frica subsahariana, Gambia no somete sistema´tica- mente a sus recie´n nacidos a un cribado de las posibles anomalı´as conge´nitas. Las infecciones quiru´rgicas (14,5%) fueron la tercera categorı´a diagno´stica ma´s frecuente, con predominio de la osteomielitis cro´nica. La osteomielitis represento´ el 5,7% de los ingresos totales, y el 15,4% de todos los dı´as de hospitalizacio´n, situa´ndose so´lo por detra´s de las quemaduras en lo tocante a esta u´ltima variable. Nuestros datos ilustran el grave problema que supone la osteomielitis para los nin˜os que viven en el A´frica subsahariana, y la enorme carga que esta afeccio´n impone a los servicios de salud. Los nin˜os gambianos rara vez eran ingresados por apendicitis, y nunca por estenosis pilo´rica hipertro´fica, dos de las afecciones de cirugı´a pedia´trica ma´s frecuentes en los paı´ses industrializados. La apendicitis ocupaba el 24o lugar en la clasificacio´n de diagno´sticos ma´s frecuentes en el momento del ingreso entre los nin˜os estudiados. Creemos que el nu´mero relativamente bajo de ingresos por apendicitis y la ausencia de casos de estenosis pilo´rica que muestra nuestra serie refleja la existencia de diferencias reales en la incidencia de esas enfermedades en la poblacio´n de Gambia. Nuestros datos indican que la prevencio´n de los traumatismos infantiles y la mejora del manejo de los traumatismos deberı´an ser intervenciones prioritarias para mejorar la cirugı´a pedia´trica en el A´frica subsahariana. La prevencio´n de los traumatismos ha tenido resultados muy satisfactorios en los paı´ses industrializados, y constituye probablemente tambie´n la estrategia ma´s eficaz con relacio´n al costo en el A´frica subsahariana. Puesto que los programas de prevencio´n no lograra´n eliminar por completo los traumatismos en la infancia, la mejora de la atencio´n dispensada a los nin˜os que los sufren tambie´n debe ser una prioridad. Nuestros datos parecen subrayar la necesidad de mejorar el manejo de los traumatismos en los niveles asistenciales primario y secundario. La atencio´n ba´sica a los traumatizados a esos niveles es indispensable para evitar la morbilidad y la mortalidad asociadas a los ingresos tardı´os. 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