Towards Holistic Paediatric Medicine and Surgery: A New Paradigm
Dr. NSY Chao
Historically Surgeons and Physicians practiced quite independently of each other with very different mindsets in their clinical care. By origins from middle-age Europe surgeons were originally 'barber surgeons' with no physician training. Even through subsequent centuries till now, the fully trained British surgeons would continue to distinguish themselves from 'Dr' physician by titling themselves 'Mr' surgeon or 'Miss' lady surgeon. But in the realms of modern health care, however, with advances in the understanding of medicine and complexity of clinical management, there are increasing collaborations between the two health care streams. Holistic clinical management seems to be a key to better patient care and clinical outcomes. Nowhere is this more relevant than in Paediatrics and Child Health. Meanwhile in recent years our editorial board enjoys receiving a growing number of manuscript submissions on Surgery related Child health topics from all over the world, partially also reflecting a global trend towards greater collaborations between Surgeons and Paediatricians in clinical practice.1,2
Advances in Neonatal Surgery has led to improved survival of neonates from many lethal neonatal and congenital conditions, but without a doubt it has also been advances in Neonatal Critical Care that has led to improved overall surgical outcomes in Neonatal Surgery. The original article herein by Ohba et al, although seemingly focused on technical interests reviewing the feasibility of single-stage repair of anorectal malformation, precisely reflects the importance holistic Neonatal Medicine with supportive perioperative critical care that makes surgery advances feasible.3 Successful endeavor of one-stage operation means obviating additional surgeries and scars plus many weeks of intensive stomal care for the parents in between surgeries.
Definitive management of Intussusception and appendicitis in children are domains of the surgeon. But of interest to the paediatrician these two very common acute abdominal conditions too often present with the general symptoms to the family physician and general paediatrician, who are faced with the grave responsibility of early suspicion with timely referral for surgical management, which is crux to good treatment outcomes. In their succinct review of cohort of ileo-colic intussusception, Kim and Lim's original article elucidates the significant rate of recurrence after initial radiological treatment, revisiting thoroughly and disputing eloquently the evidence that previously argued for ambulatory management for intussusception not requiring initial operative surgery.4
It is noteworthy that local paediatric surgical centres have observed in recent years an increasing number of complicated appendicitis presenting with significant sepsis associated with perforations and abdominal abscesses. While minimally invasive surgery is becoming a norm as definitive treatment in general, it is often a technical challenge for the young frontline surgeon during emergency setting. Indeed published data in the past did not always support minimally invasive technique over conventional open surgery for complicated appendicitis. Lv et al in their study provide substantial evidence in their astounding cohort in support of the feasibility and safety of laparoscopic surgery with comparable outcomes to open surgery in these complicated cases. Local trainee-surgeons and young specialists likewise are fast accumulating similar technical experiences with steep learning curves. It is ironically mixed blessings to our surgeons and patients.5
Biliary atresia was a devastating infantile condition before the era of Dr Morio Kasai. The greatest technical breakthrough dated back to 1951 with Dr Kasai's portoenterostomy. Together with overall advances in paediatric critical care, the operation had enormously mitigated the related infant mortality. With inherent intrahepatic disease affecting a subgroup of patients after surgery, unfortunately no further technical refinement to-date has proven to significantly improve native liver survival since Kasai's era. The main advances subsequently have been the adjunctive medical therapies endeavoring to improve jaundice clearance and native liver survival. While current clinical practice and research on this remain a hot topic among surgeons, Dong et al in their joint-effort meta-analysis between Gastroenterologists and Surgeons critically appraised the published data to contribute further robust evidence for clinicians.6 While successful liver transplant programs worldwide benefitted many long term survivors of biliary atresia, hopefully with future collaborative research in adjunctive treatments by holistic approach we may see an increase in the rate of long term native liver survival.
Locally many fields of transdisciplinary Paediatric care are already ensuing industriously with advent of our new Children's Hospital in the region. These include Neonatology, Oncology, Nephrology, Neurometabolic Medicine, Primary Cleft Care, Cardiology and many more specialties, all in collaboration with variety of surgical stream subspecialties and other clinical disciplines dedicated to children. Following suit other established children's hospitals in the world, the centralisation of complex paediatric patients and resources into this purpose-driven arena provides the ideal settings for seamless patient-centred paediatric care. We as stakeholders in child health shall enter a new paradigm with new standards of care.
Dr. NSY Chao
1. Cuff PA. Establishing transdisciplinary professionalism for improving health outcomes. ISBN 978-0-309-28901-6. 2014.
2. Wong J, Tan KY. Current challenges of surgical care and the transdisciplinary model. Transdisciplinary perioperative care in colorectal surgery: an integrative approach. 2015 Springer-Verlag Berlin Heidelberg. eBook ISBN 978-3-662-44020-9. 2015: Pages 1-11.
3. Ohba G, Yamamoto H, Nakayama M, Honda S, Taketomi A . Feasibility of one-stage correction for recto-bulbar anorectal malformations. HK J Paediar (new series) 2020;25:205-9.
4. Lim YJ, Kim KH. Is hospital admission unnecessary after successful reduction in paediatric patients with intussusception? HK J Paediar (new series) 2020;25:210-5.
5. Lv CC, Qi SQ, Huang H, Le SL, Huang BS, Xiang Y. Laparoscopic appendicectomy for complicated appendicitis in children: A retrospective study. HK J Paediar (new series) 2020;25:216-20.
6. Dong XT, Huang L, Mao DQ, Yang H. Efficacy of postoperative high-dose steroids in infants with biliary atresia: A meta analysis. HK J Paediar (new series) 2020;25:221-30.