Paediatrics is an age-based super speciality. A paediatric surgeon deals with all surgeries involving all organs of a child till 12 years of age in India. BE’s Ankita Chakraborty spoke to Dr P.K Mishra, Paediatric Surgeon, NRS Hospital, Kolkata on the scope of this particular branch of surgery.
. How did paediatric surgery come into being in India?
A. Around 35-40 years back, paediatric surgery was traditionally covered by general surgeons. Realising the need for super speciality, interested surgeons were trained for paediatric surgery. The aim was to make services more accurate and thereby enhance neonatal survival chances. In the 1960s, a bench of specialised doctors set up the Indian Association of Paediatric Surgeons (IAPS) and created training centres in Chennai, Kolkata, Mumbai and Delhi and that led to the birth of the M.Ch. course in paediatric surgery. At that point, only eight surgeons were trained annually. Gradually the numbers increased. By now, there are around 1000 paediatric surgeons in India. As time progressed, paediatric surgery courses in US, UK, China and Japan had also trained many Indian paediatric surgeons. However, the services of paediatric surgeons are confined predominantly to urban centres and remote areas are often deprived of their services.
Q. What are the major paediatric surgeries that take place?
A. Apart from anorectal malformations, atresias of gut, malrotations, Hirschsprungs disease, abdominal wall defects, cleft lip and cleft palate are common issues that require paediatric surgery. For this, the baby has to be 10 weeks of age and weigh atleast10 pounds. The haemoglobin level should also support the surgery. Hydrocephalus (accumulation of fluid in brain) just after birth also needs surgical intervention if it progresses rapidly.
In cardiac conditions, we wait and see how it advances. If it is compatible then it is okay, otherwise we intervene surgically. Regarding majority gastrointestinal issues that we deal with the conditions are mentioned above. Congenital thoracic malformation is the malformation of lungs and includes bronchial cysts, tumours and oesophageal defects.
There are cases, where the oesophagus (the food pipe) stops abruptly in the chest and does not connect with the stomach. These cases usually needs surgery. Once the baby becomes stable, we open the chest, and operate to reconstruct the upper passage.
In many cases, the diaphragm, which is the partition between the abdomen and thorax may be defective. This is formed from four sources. If there is any such defect, then the intestine, stomach, spleen, and sometimes even the kidney goes into the thorax. Left thorax is the place for the heart, so in these cases, the heart is pushed to the right side and the right lung may also be compromised. This is known as diaphragmatic hernia. This is a critical issue and infants with it need mechanical ventilation before and after the operation.
In other cases, the pylorus may be compromised. In such a situation food may not go down from the stomach to the intestine. Such a condition may occur three weeks after birth. The baby then loses sodium chloride and that leads to metabolic imbalance. In this situation we have to interfere and need to correct the sodium potassium imbalance, and treat the calcium deficiency before we can operate.
Sometimes, mal-rotation or mal-fixation of intestine occurs. For instance, the appendix instead of being in the right side may lie on the left upper abdomen. Other cases which might need operation include organ malformation, formation of stone and others.
Q. How do you diagnose these cases? How much time does it takes for these surgeries?
A. We diagnose these cases from the symptoms like pain, vomiting, distension, cyanosis, and by identifying respiratory distress. We then send the patients for investigations and proceed with the treatment accordingly. Majority of the cases are caused due to developmental malformations and malfunctions. These surgeries take around one to seven hours.
Q. What is the current state of health-awareness in our state?
A. In India, majority of the people are ignorant and there is little health awareness. Even the educated persons and many doctors are not aware of the situation, timing of surgery and often delay treatment before referring the patients to super speciality hospitals. This often causes septicaemia, electrolyte imbalance, dehydration and that impedes further treatment. Nonetheless, with evolution of technology and paediatric surgery training, there is above 80% success rate for paediatric surgery in India.
Q. What should be the post-operative care after such intensive surgeries?
A. During the post-operative period, nursing is very important. Neonatal Intensive Care Unit (NICU) and Paediatric Intensive Care Unit (PICU) are crucial for post operative survival in critical cases. We cover the patients with antibiotics to prevent sepsis. These antibiotics are supplied by the government for child patients. Intravenous (IV) fluid. Nutrition is equally important during the period. Lipid and proteins are also important, apart from electrolyte and glucose.
Q. How has paediatric surgery evolved over the years?
A. There has been a lot of evolution in the field of paediatrics and it has witnessed massive changes. At present, specialised surgeries like laparoscopic paediatric surgery, cystoscopic paediatric surgeries are all being practised by the hospitals. Robotic paediatric surgeries are likely to be undertaken soon. Concepts too have changed extensively. The spectrum of work has expanded manifold.
Q. Is the government providing adequate support to the hospitals?
A. Technically, the government is supplying enough medicines and surgical equipment to the hospitals and it can even be compared to Europian standards. Adequate training is also being provided to medical students.