The specialist paediatric surgical centre

The British Association of Paediatric Surgeons (BAPS) defines specialist paediatric surgery in four clinical categories3;

• Neonatal surgery, which involves the care of infants up to 44 weeks postconceptional age

• Complex surgical conditions requiring special expertise such as oncology, hepatobiliary disease, major trauma, and the reconstruction of congenital abnormalities

• Management of children with relatively straightforward surgical conditions who have associated disorders—for example, the child with an inguinal hernia who also has cardiac or respiratory disease and thus requires a more complicated anaesthetic

• Paediatric urology.

 For a specialist surgical centre to provide appropriate care there needs not only to be paediatric surgery but also specialists in the fields of anaesthesia, oncology, radiology, intensive care, physiotherapy, and nursing.

SURGERY

There is little disagreement with the concept that all neonatal admissions should be dealt with in neonatal surgical centres.4-6 BAPS recommends that there should be one specialist paediatric surgeon per 500 000 population.3Taking into account the heavy demand of out of hours work (40% of paediatric surgery is emergency work) and the consultant led nature of the work, it is suggested that an ideal department should be planned with no fewer than four paediatric surgeons and one paediatric urologist. Thus, 2.5 million will be the minimum population “needed to ensure that there is sufficient critical mass of workload to ensure the clinical viability and effectiveness of a specialised service”.7 This should mean that a specialist centre should see about 100 new neonatal surgical cases a year and a minimum of 60 cases to remain a viable centre. In addition, neonatal surgery makes use of complex and expensive techniques such as extracorporeal membrane oxygenation, nitric oxide treatment, and high frequency oscillation ventilation, which are best concentrated at a single regional site so that expertise and experience can be gathered by both specialist surgeons and intensivists. Table 1 shows the case load of a typical paediatric surgical centre.

With the rapid advances in antenatal diagnosis babies are no longer referred only at the time of birth, but rather parents are increasingly referred for specialist consultation and counselling from the time of prenatal diagnosis.8 Prenatal diagnosis, intervention, and fetal surgery is one of the most complex and controversial areas of medicine today. A multidisciplinary approach, involving paediatric surgeons, fetomaternal physicians, ultrasonographers, neonatologists, geneticists, and paediatricians, is essential for diagnosis of the fetus with specific anatomical defects.9It is not difficult to see why some degree of centralisation of service is required with such a large number of specialists needed to make up the team. This not only allows parents to make a rational decision on the outcome of a pregnancy but also, in conjunction with the obstetrician and neonatologist, offers fetal intervention when appropriate, and delivery in the most appropriate setting by the most appropriate route.10-12

There are also some adult conditions that specialist paediatric surgeons see infrequently. These are best managed jointly with the specialist adult surgeons; in our unit this specifically refers to thyroid cancer and specialist coloproctology, such as ileo-anal pouches.

ANAESTHESIA

The 1989 NCEPOD report stated very clearly that anaesthetists should not attempt occasional paediatric practice.2 13The risks of anaesthesia increase almost 10-fold in patients under 1 year compared with older children.14 15 In 1991 Keenanet al found a significant increase in major complications for infants anaesthetised by non-paediatric anaesthetists.16 In 1997 Auroy et alshowed that groups performing fewer than 100 paediatric anaesthetic procedures a year had a significantly increased complication rate compared with groups performing more than 200 procedures.17 Stoddart identified that a major problem of occasional paediatric anaesthetic practice is for the anaesthetist to remain up to date.18 There is broad agreement with this general philosophy19 20; however, it is not happening in practice as shown by the Digivote survey conducted by the Association of Anaesthetists Linkman Conference in 1996—only 60% of hospitals providing paediatric anaesthesia complied with the Royal College of Anaesthetists’ guidelines,21 22 and most disturbing of all only 62% of those present would be happy to allow their own children to be anaesthetised in their own hospital under its current arrangements.20

ONCOLOGY

Childhood tumours are biologically different from adult cancers. Based on the finding that survival rates of various cancers greatly improve when treated at centralised specialist centres,23the Chief Medical Officer has recommended that all cancer services be centralised and thus coordinated on a regional basis with specified surgeons operating on a required minimum number of cases each year.24 25 In particular children with cancers such as non-Hodgkin’s lymphoma, Ewing’s sarcoma, rhabdomyosarcoma, medulloblastoma, and osteosarcoma treated at paediatric oncology centres had a significantly higher survival rate.26 27Certain childhood cancers with a good prognosis, such as Wilms’s tumour, were being overtreated in non-specialist centres.28 The role of the general surgeon in paediatric oncology should be limited to arranging referral to a specialist centre.

TRAUMA

Traumatic injuries are the most common cause of death in the 1–16 age group. Fundamental anatomical and physiological differences mean that children should not simply be considered as small adults and hence the management of certain injuries differs greatly between children and adults. A good example of this is the non-operative management of blunt abdominal trauma. In specialist units, proved splenic rupture can be treated either without surgery (in 80–90% of cases) or with splenic repair in the remainder.29-32 Other injuries, such burns33 and pelvic fractures,34 have also been shown to have different management and outcome in young children. Some investigators claim that childhood trauma is equally well treated by adult surgeons at a level 1 trauma centre,35 36 while others have found improved outcome for blunt trauma in a designated paediatric trauma centre for the 0 to 11 year age group with significantly reduced rates of liver and splenic resection.32 However, all commentators state that if adult trauma surgeons are to treat children they need to develop a special interest in the management of childhood injuries. While it is impractical that all childhood trauma in the UK is managed at regional paediatric surgical centres, there is evidence to suggest that complex trauma has a better outcome with a lower operative morbidity when managed at a specialist unit.

ANCILLIARY SERVICES

Specialist paediatric surgery depends heavily for support on other specialities such as radiology, pathology, intensive care, physiotherapy, specialist nursing, and nutritionists. Better results for diagnosis and treatment of certain high risk or rare childhood disorders can be achieved by concentrating expertise; this has been shown for radiology,37 pathology,38paediatric intensive care,39-42 and neonatal intensive care.43 In many ways the debate these other specialties have regarding centralisation is remarkably similar; Murdoch and Bihari state that “Paediatric intensive care, to function well, must be associated with a full range of on-site paediatric specialties—cardiology, renal, neurology and surgery.”40 The forthcoming Troop report is expected to highlight the benefits of carefully planned paediatric intensive care provision, with centralisation of very high intensity level care. Thus specialist techniques and expensive equipment, such as high frequency oscillation, nitric oxide treatment, and extracorporeal membrane oxygenation can be evaluated and fairly rationed.

Non-specialist paediatric surgery

A number of more minor conditions, as defined in the BAPS Guide to Purchasers3 are usually treated in district general hospitals. Non-specialist paediatric surgery includes a list of common surgical complaints often dealt with in the district general hospital that do not usually require major operations or perioperative care. These include elective procedures: congenital inguinal hernia, congenital hydrocoele, circumcision, orchidopexy, umbilical hernia repair; and emergency procedures: appendicectomy, correction of torsion of the testis, repair of incarcerated inguinal hernia, and less complex trauma.

UNDESCENDED TESTES

“If you people consider the testicle to be a luxury organ to be operated on by non-specialists who am I to complain.”—Miss L Kapila, Evidence to the Royal College of Surgeons Working Party

Studies suggest the rate of orchidopexy nationally may be 2–7 times the incidence of maldescent.44 Studies by the Oxford cryptorchidism group45 suggest that the operation rates are approximately 2–3 times the incidence of undescended testis. In addition, inappropriate procedures such as blind exploration of impalpable testes are often carried out46at non-specialist centres.

INGUINAL HERNIA

It may appear that childhood inguinal hernia surgery is relatively straightforward; however, the treatment of neonatal hernias is considered by specialist paediatric surgeons as one of the most technically difficult operations, frequently taking up to two hours to complete.47 48 Complications include damage to the vas, testicular vessels, and ultimately infertility.49 50

Harper and colleagues51 highlighted two avoidable infant deaths, and NCEPOD2 reported five infant deaths from complications related to surgery and anaesthesia after treatment of an inguinal hernia in childhood; all these deaths occurred at non-specialist centres. In addition, there are published data on recurrence rates of 5% in district general hospitals, which are about double those in specialist units.52 53 Taking into account that specialist centres treat far more premature babies, this difference is likely to be even more pronounced.

CIRCUMCISION

Although male circumcision is a minor surgical procedure, it is associated with numerous complications54 including haemorrhage,55 meatal stenosis,56 and long term psychological trauma.54 57 Unless the surgeon is knowledgeable about the natural history of foreskin problems and experienced in their management, up to two thirds of operations will be performed unnecessarily58-60; this suggests more than 13 000 unnecessary circumcisions may be performed annually in the UK.

INTUSSUSCEPTION

Avoidable deaths still occur from intussusception. Stringeret al in 1992 showed that while some deaths were caused by delayed diagnosis and late referral to hospital, 60% are related to mismanagement in hospital.61 Of the patients who died in hospital only one was under the care of a specialist paediatric surgeon and he had undergone laparotomy at another district general hospital. Morbidity also occurs from avoidable laparotomy.62 More than 80% of intussusceptions can be reduced using air or barium enema37 63 when attempted by an experienced paediatric radiologist. This contrasts with the most recently reported study of intussusception from a district general hospital of a 44% resection rate of all intussusceptions.64

INFANTILE HYPERTROPHIC PYLORIC STENOSIS

The incidence of pyloric stenosis is around 3–4 per 1000 live births65 66 Thus an average district general hospital (200 000 population and 2300 live births67) should see around 6–10 cases of pyloric stenosis each year. The question of who should treat pyloric stenosis is hotly debated. Although one paper has shown good results from a district general hospital,68other reports have shown mucosal perforation rates and wound infection rates twice that of specialist centres and a wound failure rate five times those achieved within specialist centres.69 70 When the surgical care of all children at a district general hospital was transferred from general surgeons to a trained paediatric surgeon at the same hospital the complication rate fell from 33% to almost nil.71

Training

The combination of a shortened training period72 and the “new deal” on junior doctors’ hours73 has serious implications for training.74 75

Formerly training in paediatric surgery involved training in general surgery followed by training in paediatric surgery. Most neonatal surgical conditions are complex and rare; congenital diaphragmatic hernia, 1 in 2000 live births; tracheoesophageal fistulas, 1 in 4000 live births; Hirschsprung’s disease, 1 in 5000 live births. This means that either large numbers of cases need to be concentrated in one centre or training time needs to be increased (by increasing on call commitment or length of training) if we are going to achieve the case mix that is considered essential for a specialist paediatric surgeon.76 Large specialist centres allow concentration of cases that can support a minimum of five consultant paediatric surgeons and thus provide adequate training. However, the formation of NHS trusts has meant an end to regional planning and hence Trust Hospitals can set up small paediatric surgical units and appoint who they wish without regard to the national picture—as the Chief Medical Officer is aware.77

Training is also highlighted as a problem in other allied specialities such as paediatric intensive care40 and anaesthesia.18

A separate issue is the training of general surgeons and anaesthetists performing non-specialist surgery in district general hospitals. As we have highlighted there are significant differences in the reported results of treatment of non-specialist paediatric surgical conditions. NCEPOD 1989 reported that 24% of surgeons who operated on children aged 3–10 years did fewer than 20 such operations each year, and 83% operated on fewer than 20 patients who were younger than 6 months. Despite over 84 000 general paediatric surgical cases being dealt with in district general hospitals in 1994–9578 only 36 general surgeons (3%) declared it as a sub-specialty interest in a questionnaire on specialisation in general surgery.79 In 1992 the joint committee on higher surgical training’s specialist advisory committees in general and paediatric surgery agreed that general surgeons intending to undertake paediatric practice should spend at least six months training in a specialist paediatric surgical centre.80 NECPOD advised that children’s surgery in the district general hospital should be under the care of named surgeons and anaesthetists with an interest in paediatric surgery2so that occasional paediatric practice becomes a thing of the past.13 20

Summary

We have tried to review the evidence for the organisation of paediatric surgical care. Difficulties arise because of the lack of published data from district general hospitals concerning paediatric surgical conditions. Hence much of the debate about the surgical management of children is based on anecdotal evidence. However, at a time when the provision of health care is being radically reorganised to an internal market based on a system of purchasers and providers it is more important than ever to understand the issues at stake. Two separate issues have been discussed: the role of the specialist paediatric centre and the provision of non-specialist paediatric surgery in district general hospitals.

There are arguments for and against large regional specialist paediatric centres. The benefits of centralisation include concentration of expertise, more appropriate consultant on call commitment, development of support services, and junior doctor training. The disadvantages include children and their families having to travel long distances for care, and the loss of expertise at a local level. If specialist paediatric emergency transport is available the benefits of centralisation far outweigh the adverse effects of having to take children to a regional paediatric intensive care centre.21 42 Specialist paediatric centres are aware of the importance of treating children and their parents as a family unit as highlighted by the Platt committee1; this is an important challenge and enormous improvements have occurred to provide proper accommodation for families while their children are treated in hospital. To keep these arguments of large distances and separation from the home in context, one paediatric intensive care unit in Victoria, Australia, providing a centralised service to a region larger in area than England and with a similar admission rate, has a lower mortality rate than the decentralised paediatric intensive care provided in the Trent region of the UK.42

There is clear evidence that all neonatal surgery and anaesthesia should be conducted only by specialists.4 6 The debate now centres around the number of complex surgical cases a unit should treat to maintain its specialist status. The NHS executive, in its guidelines on contracting for specialist services, emphasises that “Sensible contracting needs to take into account the optimum population size not only for the stability of contracted referrals but also to give sufficient ‘critical mass’ for clinical effectiveness.”7 Achieving this balance has consequences, not just for the maintenance of surgical expertise, but for the essential ancilliary services. There is clear evidence in anaesthesia that anaesthetists doing small numbers of neonatal procedures had significantly worse results.2 13 16-18The same seems to be true in the fields of oncology,26 27radiology,37 pathology,38 and intensive care.39-41 43

The reasons why the results of management of certain paediatric conditions are better at specialist centres are open to speculation. Presumably greater exposure to rare complex cases, concentration of expertise, more peer review, and a trickle down effect of the multidisciplinary approach all help to keep health care workers up to date with current world practice. In addition, it allows for appropriate specialist on call rotas and dedicated junior staff. If insufficient numbers of specialist surgical cases are being treated at a centre then the whole multidisciplinary team suffers. The 1989 NCEPOD report states “that paediatricians and general surgeons must recognise that small babies differ from other patients not only in size, and that they pose quite separate problems of pathology and management.”2 The need for large centres of paediatric surgical expertise is now accepted by the Royal College of Surgeons of England,80 the British Association of Paediatric Surgeons,3 81 the Senate of Surgery of Great Britain and Ireland,78 the Royal College of Paediatrics and Child Health,21 the Royal College of Anaesthetists,22 the Audit Commission,⁸² and the Chief Medical Officer.77 83

The other point of debate is the role of district general hospitals providing a paediatric surgical service. Brain and Roberts have shown the benefits of a properly trained paediatric surgeon taking over the children’s surgery at a district general hospital.71 All commentators regardless of specialty or place of work (large specialist surgical centre or district general hospital) are united in their belief that occasional paediatric practice is a thing of the past.19 21 35 ⁸² 84 85 Furthermore, if surgeons and anaesthetists are to maintain a paediatric practice in a non-specialist centre, they have a duty to train appropriately, maintain their practice in line with current guidelines, and make sure that other members of the multidisciplinary team do the same.

The aims of the specialist centre and the district hospital are essentially the same—to treat patients efficiently with a consistently high level of care. The hub and spoke model described by Rollin20 has much to commend it. The aim would be a limited number of specialist centres, each surrounded by centres of competence serving local communities. For this to be achieved in line with the recommendations of the Platt report1 both types of hospital must recognise that they have aims in common and skills that are complementary. They can then work together to provide the facilities and expertise that is demanded of a children’s surgical service at both local and regional level.