THE SURGICAL NEONATE IN WEST AFRICA
In this edition of the journal is a case report by Isamade and colleagues, of a neonate with a giant sublingual cyst who presented with a “cannot intubate-cannot ventilate” scenario at induction of anaesthesia. This was successfully managed by aspiration of the cyst to achieve a clear airway.
Airway obstruction, whatever the cause, can lead to serious consequences for the patient including cardiac arrest and even death. Airway obstruction occurring at the induction of anaesthesia must be managed promptly by the anaesthetist to avoid a poor outcome. This presupposes that a competent anaesthetist and the appropriate equipment are available. Airway obstruction in a neonate presents special challenges to even an experienced anaesthetist, as the appropriate size equipment is not always available in all institutions.
The authors concluded that a needle aspiration of the cyst leading to its collapse “is a simple, safe approach of assisting airway management.” This method has been successfully used previously by Kumar and Raveenthiran and their colleagues1,2. The patient did not have any preoperative radiological investigations such as a Computed Tomography scan or Magnetic Resonance Imaging to arrive at a definite diagnosis. It is not obvious from the report why the baby did not have any of these investigations done. Were the machines available but not in working condition as is commonly seen in our hospitals? Or was it due to financial difficulties on the part of the family, a situation which is not uncommon either in our sub-region? This neonate’s swelling collapsed after needle aspiration. What if the swelling had contained a solid portion or worse still if the swelling was a teratoma and did not collapse after the needle aspiration? The outcome would have been different.
The challenges associated with management of the neonatal surgical patient in Africa have been well described by Amponsah3. Some of the concerns raised in that article are seen in this baby. The baby was born at home, presumably delivered by a traditional birth attendant (TBA). The TBAs live and work in the rural communities and they deliver a large percentage of the parturients.
Ameh and his colleagues4 from the West African sub-region indicated in a paper that 94.8% of babies were delivered at home or in a rural setting. The report clearly shows that a number of neonates who are born with congenital anomalies may die soon after birth or on their way to a health facility, due to the lack of skilled assistance and appropriate intervention at birth. Those who make it to the health facility may die due to a combination of factors including prematurity, dysmaturity5, late presentation5,6 and the complex nature of their anomalies. Some of these neonates may require multiple surgeries with the associated financial burden on their families.
This baby was fortunate that he was able to survive 7 days with the anomaly as the cyst was small at birth, and also that his parents had the resources to send him to the teaching hospital for the required surgery. Not all neonates are that fortunate3. We are not told the distance of the town from the teaching hospital. The author has managed neonates with a congenital anomaly who have travelled a 100 or more kilometres, arriving in the teaching hospital in Accra, febrile or hypothermic and dehydrated, not by an ambulance, but by public transport.
Pre-natal ultrasonography has become well established in developing countries. Pre-natal diagnosis of congenital anomalies is made, and in some instances, some pre-natal surgical interventions are carried out to improve the survival of the neonate. However, in West Africa, pre-natal ultrasonography is limited to urban areas in most countries, thus the majority of our women who live in rural areas are denied this screening opportunity.
The successful management of neonates with congenital anomalies requires experienced physician anaesthetists who can handle these babies, as well as paediatric surgeons. The number of both physician anaesthetists and paediatric surgeons are woefully inadequate in the sub-region. However the West African College of Surgeons (WACS) together with the two national Colleges in Nigeria and Ghana are training the needed specialists for the sub-region. The Francophone countries also have postgraduate training programmes in place.
Even though the numbers trained per year are small compared with the needs of the sub-region, there is hope that the numbers will increase with time. More worrying however, is the fact most of the specialists trained live and work in the urban areas. The reasons for this situation are many, and include lack of basic equipment and consumables in most of the rural health facilities, leading to frustration and a feeling of redundancy.
The Diploma in Anaesthesia programme, started about 3 decades ago by the WACS to help address the severe shortage of physician anaesthetists in English-speaking countries, has not achieved its aim, as shown in a paper by Bode and colleagues7. Perhaps the recent introduction of the membership, which is a 3-year programme for all the faculties of all the Colleges will help address some of the manpower needs of the sub-region, by better equipping the trainees. The Ghana College has had a membership programme since its inception, which has incorporated at least a 1-year compulsory posting outside the teaching hospitals. It is hoped that some of these specialists will serve permanently in non-urban areas to help in the management of some of the congenital anomalies, in health facilities not too far from locations where these babies are born. Our governments, on their part, should give incentives for the specialists who want to serve in the non-urban areas.
The use of Information and Communications Technology (ICT) in medicine is on the increase worldwide. Telementoring, for example, involving a consultant guiding a distant clinician in a new medical procedure, is being used in some countries to bridge the gap created by the shortage of specialists. The WACS can take a lead in initiating some of these ICT- based training tools. The author is hopeful that when the WACS’s own permanent secretariat is completed, some of this infrastructure will be put in place to help improve the training of fellows, members and residents. The plan by the WACS to establish the West African Surgical Skills Academy is a move in the right direction.
Mobile phones are being used to improve the outcome of pregnant women in a district in Ghana8. It is hoped that the success story will be replicated in other parts of the country as well as other countries in the sub-region to help improve the outcome of pregnancy as well as the life of the neonate. Any neonate born with an anomaly therefore may have a better chance of survival.
In conclusion the case report on the successful management of a neonate by simple aspiration of a cyst saved the life of the neonate. This success story clearly shows that with the requisite human and material resources, many more neonates with congenital anomalies may be saved. The Postgraduate Colleges of the sub-region have a major role to play in increasing access to medical care for all, irrespective of where they live and their ability to pay. The most valuable asset of any country is her people, it is important therefore to protect them when they are most vulnerable.
Prof Gladys Amponsah FWACS,
School of Medical Sciences,
College of Health and Allied Sciences,
University of Cape Coast,
Cape Coast,
Ghana.
E-mail:gamponsah2006@yahoo.com
References
- Kumar K.V, Joshi M, Vishwanath N, Akhtar T, Oak S.N. Neonatal lingual gastric duplication cyst: a rare case report. J Indian Assoc Pediatr Surg 2006; 11 (2): 97-98.
- Raveenthiran V, Sam C.J, Srinivasan K.S. A simple approach to airway management for a giant sublingual dermoid cyst. Can J Anesth 2006; 53(12): 1265-1266.
- Amponsah G. Challenges of anaesthesia in the management of the surgical neonates in Africa. Afri J Paediatr Surg 2010; 7(3): 177-182.
- Ameh EA, Dogo PM, Nmadu PT. Emergency neonatal surgery in a developing country. Pediatr Surg Int 2001; 17: 448-51.
- Sowande OA, Ogundoyin OO, Adejuyigbe O. Pattern and factors affecting management outcome of neonatal surgery in Ile-Ife, Nigeria. Surgical Pract 2007; 11:71-5.
- Ameh EA, Nmadu PT. Intestinal atresia and stenosis: A retrospective analysis of presentation, morbidity and mortality in Zaria, Nigeria. West Afr J Med 2000; 19:39-42.
- Bode CO, Olatosi J, Amponsah G, Desalu I. Has the middle-level manpower training program of the West African College of Surgeons fulfilled its objectives? Anaesth Intensive Care 2013; 41: 359-362.
- Cell phones cut maternal deaths. Accessed at www.irinnews.org/report/87261 on 25th October 2014