Epidemiological Aspects of Diseases Seen in Pediatric Surgery Consultation at the Kara Teaching Hospital

Background: Pediatric surgery in developing countries faces serious problems of inadequate infrastructures and equipment. Since July 2019, a new department was created in the north of Togo. It is in this context that this study is initiated, with the aim of taking stock of the epidemiological distribution of pediatric surgical diseases. Material and methods: This was a retrospective and descriptive study over a period of eighteen months, from October 30, 2019 to April 30, 2021. It took place in the pediatric surgery department of the Kara teaching hospital. It concerns pathologies seen at the consultation in the department collected in consultation register. Epidemiological parameters were studied. Results: In eighteen (18) months, two hundred and fifty-nine children, were seen in pediatric surgery consultation at the Kara Teaching Hospital. The annual frequency of consultations was 172.66. The monthly frequency was 14.39. The average age of the children was 4.56 years with extremes of 2 days and 15 years. There were 194 boys (74.90%) and 65 girls (25.10%). At the consultation, whatever the reason, the examination was normal in 17 children and 242 children had abnormalities. Two hundred and twelve children (81.85%) had each one abnormality and 30 children (11.58%) had each at least two. A total of 298 diseases were reported in the 242 children. These were 218 congenital diseases (73.15%) dominated by urological abnormalities with 37.16% of cases and 80 acquired diseases (26.85%). Acquired diseases were for 26.85% and dominated by limb trauma and infectious pathologies including chronic osteomyelitis. Conclusion: Pathologies seen in pediatric surgery consultation were dominated by congenital diseases. Urological malformations are the most represented. This study forms a basis for other more extensive ones.


Introduction
The first pediatric surgery department was created in Togo in 1987. Until 2015, this department was the only one in the country before campus one was created [1]. Despite this, access to pediatric surgical health care for populations in the north of the country was increasingly difficult. Thus, in July 2019, a pediatric surgery department was created at the Kara Teaching Hospital in the north of the country [2]. After its creation, the first consultation took place on 30 October 2019.
The pediatric surgery in developing countries such as Togo faces serious problems of inadequate infrastructures and equipment. To put it, Grosfel et al. [3] said that nowhere in the world is the global burden of surgical diseases more evident than in Africa. They declare that in developing countries, paediatric surgery suffers from inadequate infrastructure, financial resources and government support [3]. This situation has recently been aggravated for almost two years by the health crisis of the COVID-19 pandemic. The lack of financial resources, despite sometimes the manifest goodwill of some hospital administrators, forces them to require prioritization of the equipment to be acquired. The prioritization of its equipment, which depends primarily on the nature of pediatric surgical emergencies, also takes into account the epidemiology of pediatric surgical conditions. It is in this context that this study is initiated, with the aim of taking stock of the epidemiological distribution of pediatric surgical diseases.

Material and Methods
This was a retrospective and descriptive study over a period of eighteen months,

Results
In eighteen (18) months, two hundred and fifty-nine children were seen in pediatric surgery consultation at the Kara teaching hospital. The annual frequency of consultations was 172.66. The monthly frequency was 14.39. Figure 1 shows the monthly distribution of consultations over the eighteen months.      Malformations of the digestive system (n = 9): They were divided between anorectal malformations with 2 cases (22.22%) and Hirschsprung's disease with 7 cases (77.77%). Figure 4 shows a nine-year-old boy seen for chronic constipation in Hirschsprung's disease.
Other malformations (n = 5): 2 cases of subcutaneous hemangioma and 1 case for Poland syndrome, spina bifida and cystic lymphangioma of the neck were noted, respectively. Acquired ailments were also varied. Table 2 shows the distribution of acquired diseases according to the regions or devices concerned.
Limb trauma, infectious diseases and urogenital conditions were the most represented.

Discussion
For the first time in 2019, a pediatric surgery department was created in the northern region of Togo [2]. He is housed at the Kara teaching hospital, which is the reference hospital in the north of the country. Once the administrative act was taken in July 2019, the first consultation took place on 30 October of the same year. Indeed, the pediatric surgeon who was assigned to it was in practice in Lomé, the capital of the country, located 420 kilometers from the city of Kara. The practice of pediatric surgery in developing countries such as Togo is facing serious problems of equipment shortages, aggravated for almost two years by the health crisis of the Covid-19 pandemic. The lack of financial resources, despite sometimes the manifest goodwill of some hospital administrators, forces them to ask for a prioritization of the equipment to be acquired. The prioritization of its equipment, which depends primarily on the nature of pediatric surgical emergencies, also takes into account the epidemiology of pediatric surgical diseases. It is in this context that this study is initiated, to allow us to take stock of the proportional frequency of ailments. These data will situate the opinion on not only the frequency but also the nature of the conditions received in the service. From there, we hope that the needs and their prioritization can be more easily motivated in front of certain decision-makers.
This study was limited to diseases received in consultation. This limitation to the consultation register can be considered as a limit to this study, but we found that it showed the great diversity of pediatric surgical pathologies encountered.
Even though most of the children seen in the consultation will be hospitalized at some point, to undergo surgical procedures, the extension of a new study to hospitalized patients can give more reliable figures. Indeed, the pathologies admitted in emergency and hospitalized, for the most part, differ well from those received rather in consultation for which surgical management is often scheduled. Whatever it is, the results of this study are now original and will remain references for the pediatric surgery department of the Kara teaching and the northern region of Togo.
The annual frequency of consultations was approximately 173 in our series. It is very low compared to that reported by Gnassingbe et al. [4] in Lomé in 2010.
They had reported about 1434 consultations per year. Indeed, their study focused on the first 20 years of surgical activities of the pediatric surgery department of the Tokoin teaching hospital. This is a great period of study more significant than ours. It is not known that it would have been the annual frequency of consultations during the first two years of operation in this service. In addition to the large study period that does not allow comparison with our study, there is also the fact that the pediatric surgery department in which the study was done was the only one in the country at the time. It was therefore in this department that all cases of pediatric surgery were consulted. Since 2015, a second pediatric surgery department has been created at the Campus teaching hospital in Lomé. It had made it possible to reduce the attendance of the first service. Our pediatric surgery department created in 2019 is the 3 rd pediatric service in the country. It is closer to the population of the northern half of the country. In this context, the frequency of consultations may have decreased.
The observation of the consultation curve shows an overall increase over the months. It can be inferred from this that, an increase in consultations over time is to be expected. When consultations increase, hospitalizations will also follow. which are present at birth [5] [6]. They may or may not be clinically visible.
They represent one of the major causes of infant and neonatal mortality, especially in severe forms [6] [7] [8]. In the United States of America, they are the major cause of infant mortality. [9]. In India, 10% -15% of newborn deaths are due to congenital diseases [10]. The situation is by no means better in developing countries with high infant mortality rates, related to these malformations [7] [11] [12]. To this end, they represent a real public health problem [5] [7] [8].
The fight to reduce infant mortality from congenital diseases in developed countries has gone through several stages, the main one being the establishment of epidemiological surveillance networks for congenital diseases [9] [13]. Most of these countries have registries of birth defects and potentially teratogenic environmental agents [9]. In most developing countries, such registries are non-existent. Mortality and the incidence of congenital diseases in these countries remain speculative and without any real database. Epidemiological studies have been conducted in Lomé in Togo [4] and Abidjan (Côte d'Ivoire) [7] on congenital diseases, but they have been monocentric. However, they provided a panoramic overview of congenital diseases.
Congenital diseases in our series were dominated by urological abnormalities with 37.16% of cases. The series of Kouamé et al. [7] was characterized by the predominance of osteoarticular malformations. This predominance was found by Kouamé et al. [7] and by other authors [14]- [19]. Some studies, on the other hand, have noted a predominance of neural tube defects [20] [21] [22]. This difference in distribution could be explained by the unknown or known multifactorial origin of congenital diseases [22]. We also believe that the distribution of abnormalities in groups of congenital diseases is not uniform for all authors. As an example, we did not find in the series of Kouamé et al. [7], the abnormalities of the peritoneovaginal canal while they were classified in the urological malformations of our series.
Our study was not limited to congenital anomalies but to all diseases seen at consultation in pediatric surgery department. Thus, it made us possible to note that acquired diseases were for 26.85% of consultations. They were dominated by limb trauma and infectious pathologies including chronic osteomyelitis. Less Even limited by the study period, this study forms a basis for other more extensive ones that will encompass cases of consultation and hospitalization or that will be multicenter.

Conclusion
Pathologies seen in pediatric surgery consultation were dominated by congenital diseases. Urological malformations are the most represented. Even limited by the study period, this study forms a basis for other more extensive ones that will encompass cases of consultation and hospitalization or that will be multicenter.

Ethical Committee Approval
The authors declare having Ethical committee approval for the study.