Articles
27 June 2025
Vol. 47 No. 1 (2025)
Unique challenges in managing pediatric colorectal diseases in under-resourced areas: context-aware adaptive responses from short-term surgical outreach visits
Publisher's note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.
30
Views
19
Downloads
Authors
Pediatric Colorectal Diseases (PCRD), mainly Anorectal Malformations (ARM) and Hirschsprung's Disease, are a major issue in Sub-Saharan Africa (SSA). Even with advances in healthcare facilities and global health initiatives, most of children living in low resources SSA lack of specialist pediatric surgical facilities. Improved healthcare access is needed to manage PCRD in these locations, to prevent and reduce missing or delayed diagnosis, early mismanagement by inexperienced health practitioners, and barriers to corrective therapy and long-term follow-up. A retrospective analysis of data from three SSA hospitals shows that international surgical outreach visits helped increase capacity. Along one hundred twentyfour weeks of staggered surgical outreach visits 174 ARM and 64 highly suspected HSCR cases were collected. The study evaluates 152 ARM and 59 HSCR patients who had not been treated before. Those who came after an unsuccessful treatment elsewhere were not included. Management, clinical course, complications and results are reported. Focus is on context-aware adaptive surgery and sustainable solutions to improve outcomes and quality of life for those children, discussing long-term follow-up options and results. The local context has a substantial impact on epidemiology, demographics, and presentation compared to high-resource countries. Intestinal stomas done at a primary health facility level presented at referral to our Hospital with 25% complication rate. Due to social, economical, and transit issues, only 108 ARM and 41 HSCR could finally receive a corrective treatment by the outreach visiting teams. Complications (9.1%) were controlled using adaptive solutions. Only one surgical fatality occurred. A limited proportion of patients (46% ARM, 31% HSCR) attended a regular follow up schedule for one year or more, and finding those lost in wide rural areas was difficult. Successful and comprehensive PCRD management in under-resourced SSA requires better training at the primary health level on early recognition and correct, first surgical approach, together with a referral network to specialist facilities for further treatment. Surgical short-term outreach trips can boost local capability in under-resourced areas. The research of adaptive and sustainable surgical solutions to reduce hospital stay and staged treatments time for PCRD must be emphasised. Nevertheless financial and logistical constraints still challenge post-discharge monitoring and follow-up, which remain crucial for long-term outcome.
Altmetrics
Downloads
Download data is not yet available.
Citations
1. Purcell L, Ngwira N, Gallaher J, Cairns B, Charles A. Characteristics and outcomes in paediatric patients presenting with congenital colorectal diseases in sub-Saharan Africa. Trop Doct 2019;49:256-9. DOI: https://doi.org/10.1177/0049475519851010
2. Gajewski J, Pittalis C, Borgstein E, et al. Critical shortage of capacity to deliver safe paediatric surgery in sub-Saharan Africa: evidence from 67 hospitals in Malawi, Zambia, and Tanzania. Front Pediatr. 2023 May 31; 11:1189676. DOI: https://doi.org/10.3389/fped.2023.1189676
3. Calisti A, Nugud FA, Belay K, Mlawa A, Chiesa PL. Pitfalls and technical errors in the first approach to neonates with anorectal malformations in a non-specialist context: can we do any better? A review from three Eastern African Centres. Afr Health Sci 2021;21:1340-5. DOI: https://doi.org/10.4314/ahs.v21i3.45
4. Pena A, Migotto-Krieger M, Levitt MA. Colostomy in anorectal malformations: a procedure with serious but preventable complications. J Pediatr Surg 2006;41:748-56. DOI: https://doi.org/10.1016/j.jpedsurg.2005.12.021
5. Seth I, Lim B, Cevik J, et al. Impact of nutrition on skin wound healing and aesthetic outcomes: A comprehensive narrative review. JPRAS Open 2024;39:291-302. DOI: https://doi.org/10.1016/j.jpra.2024.01.006
6. Olivieri C, Belay K, Coletta R, et al. Preventing posterior sagittal anoplasty 'cripples' in areas with limited medical resources: a few modifications to surgical approach in anorectal malformations. Afr J Paediatr Surg 2012;9:223-6. DOI: https://doi.org/10.4103/0189-6725.104724
7. Tresphory B, Mlawa A, Calisti A. Pull-through of ganglionic stoma in children with Hirschsprung's disease living in a low resource context spares further surgery for colostomy reversal: a report from a Tanzanian regional referral hospital. Afr J Paediatr Surg 2023;20:302–5. DOI: https://doi.org/10.4103/ajps.ajps_57_22
8. Xie X, Pei J, Zhang L, Wu Y. Global birth prevalence of major congenital anomalies: a systematic review and meta-analysis. BMC Public Health 2025;25:449. DOI: https://doi.org/10.1186/s12889-025-21642-6
9. You D, Beise J, Lee S, et al. Demographic challenges and opportunities for child health programming in Africa and Asia. BMJ 2021;372: n19. DOI: https://doi.org/10.1136/bmj.n19
10. Bryce E, Fedatto M, Cunningham D. Providing paediatric surgery in low-resource countries. BMJ Paediatr Open 2023;7:e001603. DOI: https://doi.org/10.1136/bmjpo-2022-001603
11. Therrell BL Jr, Lloyd-Puryear MA, Ohene-Frempong K, et al. Empowering newborn screening programs in African countries through establishment of an international collaborative effort. J Community Genet 2020;11:253-68. DOI: https://doi.org/10.1007/s12687-020-00463-7
12. Smith ED. Incidence frequency of types and etiology of anorectal malformations. Birth Defects Orig Arctic Ser 1988;24:238–40.
13. Trinidad S, Kayima P, Kotecha V, et al. Hirschsprung's disease in low- and middle-income countries. Semin Pediatric Surg 2022;31:151163. DOI: https://doi.org/10.1016/j.sempedsurg.2022.151163
14. Moore SW, Alexander A, Sidler D, et al. The spectrum of anorectal malformations in Africa. Pediatr Surg Int 2008;24:677-83. DOI: https://doi.org/10.1007/s00383-008-2131-y
15. Olumide F, Adedeji A and Adesola AO. Intestinal obstruction in Nigerian children. J Pediatr Surg 1976;11:195–204. DOI: https://doi.org/10.1016/0022-3468(76)90287-6
16. Shah M, Gallaher J, Msiska N, et al. Pediatric intestinal obstruction in Malawi: characteristics and outcomes. Am J Surg 2016;211:722–6. DOI: https://doi.org/10.1016/j.amjsurg.2015.11.024
17. Kimario FF, Festo C, Shabani J, Mrisho M. determinants of home delivery among women aged 15-24 years in Tanzania. Int J MCH AIDS 2020;9:191-9. DOI: https://doi.org/10.21106/ijma.361
18. Brisighelli G, Loveland J, Bebington C, et al. Do social circumstances dictate a change in the setup of an anorectal malformation clinic? J Pediatr Surg 2020;55:2820-3. DOI: https://doi.org/10.1016/j.jpedsurg.2020.03.012
19. Leke AZ, Malherbe H, Kalk E, et al. The burden, prevention and care of infants and children with congenital anomalies in sub-Saharan Africa: A scoping review. PLOS Glob Public Health 2023;3:e0001850. DOI: https://doi.org/10.1371/journal.pgph.0001850
20. Yap A, Olatunji BT, Negash S, et al. Out-of-pocket costs and catastrophic healthcare expenditure for families of children requiring surgery in sub-Saharan Africa. Surgery 2023;174:567-3.
21. El Vilaly MAS, Jones MA, Stankey MC, et al. Access to paediatric surgery: the geography of inequality in Nigeria. BMJ Glob Health 2021;6:e006025. DOI: https://doi.org/10.1136/bmjgh-2021-006025
22. Commander SJ, Ellis D, Williamson H, et al. Social and financial barriers may contribute to a "hidden mortality" in Uganda for children with congenital anomalies. Surgery 2021;169:311-7. DOI: https://doi.org/10.1016/j.surg.2020.09.018
23. Munyali A, Buhendwa C, Ganywamulume B, et al. Adolescent anorectal malformations: Case series about 3 cases. Int J Surg Case Rep 2025;127:110913. DOI: https://doi.org/10.1016/j.ijscr.2025.110913
24. Lawal TA. Overview of anorectal malformations in Africa. Front Surg 2019;6:7. DOI: https://doi.org/10.3389/fsurg.2019.00007
25. Dworschak GC, Zwink N, Schmiedeke E, et al. Epidemiologic analysis of families with isolated anorectal malformations suggests high prevalence of autosomal dominant inheritance. Orphanet J Rare Dis 2017;12:180. DOI: https://doi.org/10.1186/s13023-017-0729-7
26. Smith CA, Avansino J. Anorectal Malformations. [Updated 2023 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK542275/
27. Archibong A, Idika I. Results of treatment in children with anorectal malformations in Calabar, Nigeria. South Afr J Surg 2004;442:88–90.
28. Mfinanga RJ, Massenga A, Mashuda F, et al. Clinical profile and outcome of surgical management of anorectal malformations at a tertiary care hospital in Tanzania. Tanzania J Health Res 2018;20:1–11.
29. Nah SA, Ong CC, Lakshmi NK, et al. Anomalies associated with anorectal malformations according to the Krickenbeck anatomic classification. J Pediatr Surg 2012;47:2273-8. DOI: https://doi.org/10.1016/j.jpedsurg.2012.09.017
30. Murphy F, Puri P, Hutson JM, Holschneider AM. Incidence and frequency of different types, and classification of anorectal malformations. In Holschneider AM, Hutson JM, (eds.). Anorectal malformations in children embryology, diagnosis, surgical treatment, follow-up. Springer-Verlag Berlin Heidelberg 2006, pp 251-62.
31. Hageman IC, Midrio P, van der Steeg HJJ, et al. The European Anorectal Malformation Network (ARM-Net) patient registry: 10-year review of clinical and surgical characteristics. Br J Surg 2024;111:znae019. DOI: https://doi.org/10.1093/bjs/znae019
32. Oyania F, Faktor K, Ullrich S, et al. Delayed diagnosis of anorectal malformations: a call for standardization of the current definitions. World J Pediatr Surg 2024;7:e000960. DOI: https://doi.org/10.1136/wjps-2024-000960
33. Chatterjee SK. Rare/Regional variants. In Holschneider AM, Hutson JM (eds.). Anorectal malformations in children embryology, diagnosis, surgical treatment, follow-up. Springer-Verlag Berlin Heidelberg 2006, pp 251-62.
34. Nasir AA, Adeniran JO, Abdur-Rahman LO. Hirschsprung disease; 8 year’s experience in a Nigerian teaching hospital. J Indian Ass Pediatr Surg 2007;12:68–7. DOI: https://doi.org/10.4103/0971-9261.33210
35. Mabula JB, Kayange NM, Manyama M, et al. Hirschsprung's disease in children: a five-year experience at a university teaching hospital in northwestern Tanzania. BMC Res Notes 2014;7:410. DOI: https://doi.org/10.1186/1756-0500-7-410
36. Ba A, Thiongane A, Sow NF, et al. Prevalence and clinical characteristics of chronic constipation in senegalese children. Open J Pediatr 2023;13:921-8. DOI: https://doi.org/10.4236/ojped.2023.136101
37. van Andel T, van Onselen S, Myren B, et al. "The medicine from behind": The frequent use of enemas in Western African traditional medicine. J Ethnopharmacol 2015;174:637-43. DOI: https://doi.org/10.1016/j.jep.2015.06.040
38. Ekenze SO, Ngaikedi C, Obasi AA. Problems and outcome of Hirschsprung's disease presenting after 1 year of age in a developing country. World J Surg 2011;35:22-6. DOI: https://doi.org/10.1007/s00268-010-0828-2
39. Bandré E, Kaboré RA, Ouedraogo I, et al. Hirschsprung's disease: management problem in a developing country Afr J Paediatr Surg 2010;7:166-8. DOI: https://doi.org/10.4103/0189-6725.70418
40. Poenaru D, Borgstein E, Numanoglu A, Azzie G. Caring for children with colorectal disease in the context of limited resources. Semin Pediatr Surg 2010;19:118-27. DOI: https://doi.org/10.1053/j.sempedsurg.2009.11.017
41. Tyson AF, Msiska N, Kiser M, et al. Delivery of operative pediatric surgical care by physicians and non-physician clinicians in Malawi. Int J Surg 2014;12:509-15. DOI: https://doi.org/10.1016/j.ijsu.2014.02.009
42. Grabski DF, Ajiko M, Kayima P, et al. Access to pediatric surgery delivered by general surgeons and anesthesia providers in Uganda: Results from 2 rural regional hospitals. Surgery 2021;170:1397-404. DOI: https://doi.org/10.1016/j.surg.2021.05.007
43. Gerçel G, Azizoglu M, Karakas E, et al. Comparing loop and divided colostomy for anorectal malformation: a systematic review and meta-analysis. J Pediatr Surg 2025;60:161974. DOI: https://doi.org/10.1016/j.jpedsurg.2024.161974
44. Brisighelli G, Etwire V, Lawal T, et al. Treating pediatric colorectal patients in low- and middle-income settings: Creative adaptation to the resources available. Semin Pediatr Surg 2020;29:150989. DOI: https://doi.org/10.1016/j.sempedsurg.2020.150989
45. Okoye MT, Nguyen ET, Kushner AL, et al. Can economic performance predict pediatric surgical capacity in Sub-Saharan Africa? World J Surg 2016;40:1336-43. DOI: https://doi.org/10.1007/s00268-016-3410-8
46. Toobaie A, Emil S, Ozgediz D, et al. Pediatric surgical capacity in Africa: Current status and future needs. J Pediatr Surg 2017;52:843-8. DOI: https://doi.org/10.1016/j.jpedsurg.2017.01.033
47. Ekenze SO, Jac-Okereke CA, Nwankwo EP. Funding paediatric surgery procedures in sub-Saharan Africa. Malawi Med J 2019;31:233-40. DOI: https://doi.org/10.4314/mmj.v31i3.13
48. Yap A, Olatunji BT, Negash S, et al. Out-of-pocket costs and catastrophic healthcare expenditure for families of children requiring surgery in sub-Saharan Africa. Surgery 2023;174:567-73. DOI: https://doi.org/10.1016/j.surg.2023.05.010
49. Oshvandi K, Zamanzadeh V, Ahmadi F, Fathi-Azar E, Anthony D, Harris T. Barriers to nursing job motivation. Res J Biol Sci 2008;3:426–34.
50. Lawal TA, Olulana DI, Ogundoyin OO. Spectrum of colorectal surgery operations performed in a single paediatric surgery unit in sub-Saharan Africa. Afr J Paediatr Surg 2014;11:128-31. DOI: https://doi.org/10.4103/0189-6725.132802
51. van Zyl C, Badenhorst M, Hanekom S, Heine M. Unravelling ‘low-resource settings’: a systematic scoping review with qualitative content analysis. BMJ Global Health 2021;6:e005190. DOI: https://doi.org/10.1136/bmjgh-2021-005190
52. Lawal TA. Management of postoperative fecal incontinence by pediatric surgeons in Nigeria: a pilot study. Ann Pediatr Surg 2020;16:25. DOI: https://doi.org/10.1186/s43159-020-00037-9
53. Krois W, Gröpel P, Hernandez PX, et al. The effect of pediatric colorectal short-term medical service trips on self-reported confidence in patient care in volunteers in the home country. Ann Glob Health 2020;86:28. DOI: https://doi.org/10.5334/aogh.2744
54. Massenga A, Chibwae A, Nuri AA, et al. Indications for and complications of intestinal stomas in the children and adults at a tertiary care hospital in a resource-limited setting: a Tanzanian experience. BMC Gastroenterol 2019;19:157. DOI: https://doi.org/10.1186/s12876-019-1070-5
55. Youssef F, Arbash G, Puligandla PS, Baird RJ. Loop versus divided colostomy for the management of anorectal malformations: a systematic review and meta-analysis. J Pediatr Surg 2017;52:783-790l. DOI: https://doi.org/10.1016/j.jpedsurg.2017.01.044
56. Woods A, Shofner C, Hodge B. International pediatric surgery partnerships in sub-Saharan Africa: a scoping literature review. Glob Health Action 2022;15:2111780. DOI: https://doi.org/10.1080/16549716.2022.2111780
How to Cite
Unique challenges in managing pediatric colorectal diseases in under-resourced areas: context-aware adaptive responses from short-term surgical outreach visits. (2025). La Pediatria Medica E Chirurgica, 47(1). https://doi.org/10.4081/pmc.2025.357
Copyright (c) 2025 the Author(s)
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
PAGEPress has chosen to apply the Creative Commons Attribution NonCommercial 4.0 International License (CC BY-NC 4.0) to all manuscripts to be published.
