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Where should paediatric surgery be performed?
  1. K A WILKINSON, Consultant Anaesthetist,
  1. Jenny Lind Children’s Department
  2. Norfolk and Norwich Hospital
  3. Brunswick Road, Norwich NR1 3SR, UK
    1. P CROWLE, Consultant Paediatrician
    1. Jenny Lind Children’s Department
    2. Norfolk and Norwich Hospital
    3. Brunswick Road, Norwich NR1 3SR, UK

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      Editor,—Arul and Spicer’s recent review1 on this controversial issue failed to address some of the most important points surrounding regionalisation of paediatric surgery. Other papers on the subject are equally unrewarding2 3 and so perhaps there is a need for more debate.

      We must balance the need to banish “occasional paediatric practice”4 with the rightful concerns about providing “a child and family centred service in which skilled help is readily available and accessible”.5

      The arguments used by the authors on centralisation of paediatric intensive care do not necessarily support the need to regionalise paediatric surgery along the same lines. Paediatric intensive care is a low volume, high risk speciality requiring the skills and equipment justified in only a few UK centres. In contrast the vast majority of surgery on children in the UK is low risk, high volume work very, little of which requires on site specialist paediatric facilities. Paediatric surgery is however attended by significant morbidity if the wrong decisions are made; such morbidity may only be revealed several years later.

      Nevertheless we are urged to move towards a model where one paediatric surgical centre serves the specialist surgical needs of a population of 2.5 million and the non-specialist needs of 1.2 million. The remaining 1.3 million children with non-specialist needs in this model would be served by the general surgeon with a paediatric interest (a rare breed according to a recent Senate of Surgery report6). However, according to guidance issued by the British Association of Paediatric Surgeons to purchasers2 such centres might be responsible for cases such as elective repair of congenital inguinal hernia, undescended testis, and circumcision. Arul and Spicer are rightly concerned that the skills required to deal with these problems are considerable if long term morbidity is to be prevented.

      In a larger district general hospital such as Norwich, 3000 children under 12 have operations each year. A large proportion of this work is done by two paediatric surgeons. This gives the surgeon, anaesthetist, and more importantly managers the numbers to provide extra facilities and produce a first rate local service for children. As well as medical staff it involves a dedicated, separate provision for children from operating theatre, recovery room, and day care centre to the provision of pain relief, and beyond. Removing our paediatric surgeons would have a significant spin off effect in making the total provision of service less cost effective and more prone to inadequate investment.

      If we all believe that children’s surgery should be done by paediatric surgeons (as happens in most developed countries) it is nonsense to make plans of which the main side effect is so much surgery being done by a dying breed of general surgeons with a paediatric interest.

      References

      Mr Arul and Spicer comment:

      Drs Wilkinson and Crowle seem to have missed the central tenet of our paper, which is the importance of distinguishing between general and specialist paediatric surgery. While a specialist paediatric surgeon should help to train and advise general surgeons with an interest in paediatric surgery, there are guidelines published for surgery and anaesthesia to be safely performed in a district general hospital.1-1 1-2

      The raison d’etre of the paediatric surgeon is specialist surgery. Almost by definition this type of surgery requires neonatal and paediatric intensive care as well as a support structure that includes specialist radiologists, pathologists, and nurses. The 3000 children that Wilkinson and Crowle state are operated on in Norwich probably include a large number of “ear, nose, and throat” and non-specialist general surgical operations. The most important data to consider is how many neonates and infants are involved and how many required intensive care postoperatively?

      The last set of figures that were published by the British Association of Paediatric Surgeons shows that Norwich operated on 50 neonates a year while Cambridge, within the same region, operated on 20 neonates.1-3 Hence both centres are seeing fewer than the 60 surgical neonates considered essential to maintain expertise.1-4 If, however, they were to combine then there would be a viable centre. The benefits would be immediate. Instead of working a one-in-two on call rota with no middle grade specialist registrar cover, the consultants could organise a much more acceptable rota. The paediatric surgeons could start to develop further special interests; appropriate training of specialist registrars could begin; anaesthetists could start to organise themselves into a paediatric on call rota; and ward nurses would start to see sufficient numbers of high risk complex surgical cases to gain essential experience.

      The point of our paper was not to “take away their paediatric surgeons” but rather to suggest that with careful organisation of a service on a regional basis, all hospitals in their region would be better served with both specialist and non-specialist paediatric surgery.

      References

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