Epidemiological Study of Pediatric Surgery at Regional Hospital of Sorocaba between 2008 and 2012 by a Single Surgeon

Introduction: volume increase of Pediatric Surgery (PedSur) due to factors not yet fully clarified contrast with the scarcity of pediatric surgeons in Brazil and globally. Geographic distribution, surgical care costs, and graduation period might contribute to this dearth. In Brazil, vacancy occupation rate in PedSur is below 43% (162 vacancies/year). Aim: analyze the volume of procedures performed on 0 12 year-old patients in PedSur by a single Specialist at Hospital Regional (HR); compare with the literature and propose the outset of a PedSur Medical Residence program. Material & Method: 1912 attendances were fulfilled on 986 children who were submitted to surgical procedures between 2008 and 2012 at HR by a single specialist. Results: Surgical procedures were performed on 1137 children, an average of 227/year or 197 children per year. Surgery was carried out in 667 (68%) boys and 319 (32%) girls. Hernias, appendectomies and circumcisions were the most frequent external surgeries. 437 (44%) patients were discharged on the same day and, 549 (56%) were hospitalized. In the Pediatric ICU and in the Neonatal ICU 181 procedures were performed (18%). Conclusion: It was possible to make evident the distribution of surgeries on children, the degree of complexity and a sufficient number of subjects for training in this Specialty. The obtained data allow the development of a study with regards to the inception of a Medical Residence in PedSur at HR for training and retaining the professional in the region.


Introduction
Despite the increase of volume in Pediatric Surgery (PedSur), there is a decrease in the working capacity of pediatric surgeons in USA and worldwide which has not been properly clarified [1] [2].Geographic distribution, surgical care costs, social statistics and this specialist graduation period might explain this still limited distribution of labor force in PedSur [2].A significant group of children have been operated by other specialties, such as urology, whereas pediatric surgeons are usually engaged in the correction of hernias (primary and recurrent), corrections using laparoscope in younger children and girls.On the other hand, pediatric urologists operate most frequently hydrocelectomies (62%), orchiopexies (83%) [3].
In a research done through the Internet with members of the American Pediatric Surgery Association (APSA), a minority of PedSur specialists who answered the questionary asserted that unspecialized PedSur surgeons have treated selected children cases in their communities.In their replies, they mentioned inguinal, umbilical hernias; abscesses and trauma.Nearly 20% of the respondents expressed interest to count on a PedSur partner who would substitute them in their surgical procedures [4].
Despite the scarcity of pediatric surgeons, training programs in PedSur have had a swift growth in North America.Moreover, the quality of patient care, surgical education, practical activities and training are thoroughly monitored [5].A research in Canada and USA was conducted and analyzed by categories, such as neonatal; oncologic; thoracic; cardiac; urologic; reconstructive; head and neck; vascular, plastic surgeries procedures in burned patients.Routine surgeries showed a slight difference between training programs, as well as experience among surgeons.There are services in which PedSur iconic surgeries, such as esophagus atresia, bile duct atresia, and inter-sex atresia are scarce or not performed in some training programs [4].In spite of this upturn in PedSur programs, it doesn't seem that they have significantly affected the exposure to and surgical experience in highly specific specialties.Moreover, PedSur programs have concurred that there is a growing variability among these programs [6].
It was not only the amount, the type of surgeries performed, and the surgeons' experience that was studied in the different services offered at PedSur.Teaching quality in Medical Schools was also analyzed.In spite of the inclusion of the concept of quality improvement of the curriculum of several Medical Schools in USA and United Kingdom, there are significant differences in the offer of these topics in the undergraduate and in the period of medicine students' qualification that has shown variable degrees of exposure to the concept of quality improvement [7].In 2013, 90 thousand deaths were attributed to medical malpractice in the USA.Since then, the introduction of a curricular program for the patients' safety and quality improvement in medical schools has become the focus of study worldwide.Despite this consensus, few medical schools have implemented directives aimed at this objective.Moreover, there are few evidences regarding an improved teaching method for this subject [8].
In Brazil, the concern is not only PedSur services, but the lack of interest and consequently these specialty services don't attract students, as described by Jesus et al., 2009 [9].The latter can be verified by comparing the numbers of openings offered for enrollment in PedSur in Brazil (162) and the number of openings filled (70, or merely 43%).These authors have also assessed PedSur qualification degree using the best results, especially in trauma, appendicitis, urological cases and specialties related to other cases when children are operated."The ideal solution would be the increment of professionals' attending availability" that suggests the possibility of graduating new specialized professionals in PedSur [9].
The health attending level of Hospital Regional (HR) at the Conjunto Hospi-

Material & Method
In this retrospective descriptive study of 1912 documented attendances in the Book of Ambulatory Attendance of an individual Pediatric Surgeon between 2008 and 2012 at HR/CHS in PedSur specialty were analyzed.In this Service, there are 5 other professionals of the same specialty, whose surgeries were not assessed in this analysis.All the information detailed in the book is described in the present study.
The information obtained from the data of 1137 surgical procedures performed in 986 children is shown per year, per hospitalization regimen and type of surgery.
In surgeries totalizing 1137 procedures performed in 986 children, 437 (44%) were medically discharged on the same day after an observation period of 4 -5 hours.Additional 549 children (56%) were operated in a prolonged hospitalization regimen (Table 2).
Regarding the 1137 surgical procedures performed on 986 children, 437 (44%) were discharged on the same day after a period of observation of 4 -5 hours on the average.Other 549 children (56%) were operated with a prolonged hospitalization regimen (Table 2).
Table 3 shows the distribution of the children who were submitted to surgery in the period between 2008 and 2012 by type of surgery and gender.In the group of children who were operated 667 were boys (68%) and 319 girls (32%).More  were discharged on the same day after an average period of observation of 4 -5 hours.Other 549 children (56%) were operated on a prolonged hospitalization regimen, (Table 2).When comparing the number of operated patients who remained hospitalized with the number of patients in Day Clinic regimen, a significant statistical difference was observed, with p = 0.0004 (the expected frequency was calculated based on the hypothesis that both were equal, that is, 493 surgeries).Concerning sex, the number of boys and girls submitted to surgery was not statistically significant different concerning the percent distribution throughout the 5-year study, despite the mesmo o número de meninos ser maior (p = 0.6396).
In the neonatal period, 266 children (27%) were operated and hospitalized in the Pediatric Intensive Care Unit (PICU) or in the Neonatal Intensive Care Unit (NICU).In these sectors 181 small surgical procedures, highlighted in Table 4, were performed totalizing 18% of the operated children (986).Central venous access was the most frequent technique with 111 surgical procedures (61%) and 11% when compared to the total number of operated children (986).
Some of these children were submitted to 2 gastrostomies in 2 esophagus atresia without tracheoesophageal fistula and 13 colostomies in cases of high anorectal anomalies or in children bearing vestibular fistulas which has been accounted for in Table 4.In PICU and NICU 181 procedures totalizing 19% of all the procedures performed in this period (Table 4).
Regarding the 4 surgeries that are frequently performed at PICU and NICU, the study shows significant statistical difference (p = 0.0001), given that venous access was frequently used.

Discussion
The number of children who need specialized surgical procedures is becoming greater with an increase of 21% since 2005 [1] [11].The same occurred in the period of the current study in which a 5% rise was observed (p < 0.0001).Despite the increase of SurPed demand, there is a worldwide decline in the number of pediatric surgeons, especially in Brazil where the openings for residents in this specialization didn't surpass 45% in 2009 [9].The numbers of children who need specialized surgery are greater than the health system is capable of attending.Consequently, children have been operated by other specialties, such as urology [3].This is brought about by negligence in essential aspects of child surgery that should be based on clinical evidence and the effective costs of the treatment, aiming at providing benefits to an escalating number of children [12].
performed in the same period in 2009 (222) and 2012 (233), an evolution with similar tendency to the increase presented in the literature [2] [5].The objective of the actual retrospective descriptive study was to analyze the magnitude of 1137 procedures performed on 986 children with ages from 0 to 12 years by an individual Pediatric Surgeon at the PedSur Service of HR/CHS between 2008 and 2012 comparing data obtained with other published studies [2].Moreover, this study aims at demonstrating the feasibility of a Medical Residency start-up program in Pediatric Surgery at HR/CHS.These new specialists shall be part of the work force in PedSur in the city and the region[4].

[ 9 ]
.De Jesus et al., 2009, also considered as a criterion of the ideal activity in a surgical center for a pediatric surgeon approximately 3 surgeries/day; four days/ week; 40 weeks/year and each pediatric surgeon has to perform 480 surgeries/ year[9].Through the data analysis of the current study, it is possible to offer to the PedSur Resident to undertake a task with an individual Specialist of the service, and exposure to an average of 220 surgeries per year of which 36% are performed in the neonatal period.The analysis of procedures performed in children from 0 to 12 years old by an individual Pediatric Surgeon of PedSur Service at CHS/SP emphasized the distribution of the most frequent surgeries performed, their degree of complexity, training and qualification.If the statistical data of the 5 Pediatric Surgeons had been computed, certainly the gradual increase of PedSur would be more evident.Despite of PedSur high demand and the prompt increase of training programs inUSA[5], there is still a PedSur shortage worldwide, and mainly in Brazil[9] [14].On the other hand, this study showed an increase of pediatric surgeries in the years of 2008, 2009 and 2012 when comparing with 2010 and 2011, with a significant statistical difference p < 0.0001.The data obtained in this retrospective analysis are coincident with literature data with regards to worldwide increase of demand for PedSur.These data suggest a great variety of surgeries in children and the possibility of starting an academic PedSur Medical Residence at HR aimed at training, professional permanence in the region and high quality standard child care[4] [15].After all, the analyzed data shown herein are solely the result of the work of one of the 6 Pediatric Surgeons of HR.

Table 1 .
Distribution of appointments, patients and surgeries in the years 2008 up to 2012.The number of appointments is higher than the surgeries, given that some children were attended at the ambulatory more than once.
*Average of 383 attendances per year.**227 surgeries per year per individual surgeon.

Table 3 .
Distribution of children submitted to surgical procedures by surgery type and sex from 2008 up to 2012, in addition to the sectors of Ped ICU (PICU) and Neonatal ICU (NICU).

Table 3
shows the distribution of children operated in the period from 2008 up to 2012 by type of surgery and sex.Within the group of children submitted to surgery 667 were boys (68%) and 319 were girls (32%).More than one operative procedure was performed on 151 children (15%): 116 boys (77%) and 35 girls (23%).

Table 4 .
Distribution of the most recurrent surgeries performed at PICU/NICU by an individual specialist in PEDSUR at CHS between 2008 and 2012.Percentages were calculated based in the total number of children who were operated in PICU/NICU (181).**In the surgeries in the neonatal period, 13 Colostomies were performed in newborns bearers of High Anorectal Malformation and vestibular fistulae and 2 Gastrostomies in children bearers of Esophageal Atresia without tracheoesophageal fistulae.