This paper is a critical analysis of the process of children’s care after surgical interventions with a special interest in the evolution of the patient and the long-term solvency of the follow-up.
It is natural that doctors who have a specialization in surgery think about how to improve their skills and their surgical techniques. However, they fail to pay attention to the substantial value that the accompaniment and the follow-up have. Indeed, in pediatric surgery and mainly neonatal surgery, the logic of pediatric surgeons should be different. The first surgical intervention, which will correct congenic malformations, must have optimal standards in its planning, development, and surgical techniques; it must be precise in its execution, but at the same time or even with more attention, surgeons should consider that there is something beyond the technique. Surgeons must be prepared to face complications and offer better follow-up and long-term advice.
Over the last fourth decades, the development of health care of the pediatric surgical patient has been full of new proposals and accelerated technical challenges that have undoubtedly triggered the improvement of technical skills and academic preparation for pediatric surgeons. It has been a frenzied tendency to use new drugs, nutrients, technology, biotechnology, and better communications systems. For example, it has been thirty-six years since the first application of Posterior Sagittal Anorectoplasty, the technique that marks a before and an after of the contemporary pediatric surgery. Also, the development of parenteral nutrition has been fundamental in the resolution of critical and neonatal processes. Moreover, the development of "assisted video surgery” as well as endoscopic surgery through natural orifices (NOTES), and the single incision laparoscopic surgery, the fetal surgery, and the robotic surgery are examples of several transformations in the area. In addition, the development of modern communications systems, which have invaded all social networks around the globe, offers great academic opportunities. Today, it is difficult to miss the last “comment” of "webmaster” in pediatric surgery, which may have been published a few minutes ago
Fantastic! It is how we qualified the development and implementation of technological improvements that helped us to offer comfort and security to surgical treatments. However, the commitment as pediatric surgeons --mainly those who care for children with congenic malformations-- must exceed the expectations regarding the good implementation of technical skills and surgeon’s dexterity. They need to remember that the majority of these children will remain under their follow-up for the rest of their lives.
So, we asked, are the innovation of surgical techniques, their implementation, and execution by themselves effective and efficient to control physiopathology of malformations? Will they provide long-term security, without provoking big complications, difficulties, and agonizing recovery processes in children? These questions highlight the importance to consider the preservation of “native esophagus” with esophageal elongation techniques. They also highlight radical changes in children’s physiology when we execute gastric ascent for substitutions. And the “simple derivations” laparoscopic management of a duodenal duplication cyst to perform choledochal cysts, when it is well know that if doctors do not dry up these cysts, it predisposes patients to the appearance of malignancy in long-term; or the performance of pyeloplasty in kidney with deficient renal cortex and uncertain recovery of the renal parenchyma.
After the literature review of an extensive database from Medline, Cochrane and other specialized journals, only 20% of them refer to long-term follow-up of certain pathologies such as children with anorectal malformation, esophageal atresia, cryptorchidism, and pyelocalyceal cyst, etc. It is most common to read articles that analyze the success and improvements of surgical techniques, forgetting the patient’s future evolution.
This deficiency is due to multiple factors, including the lack of adequate post surgery follow-up in both, the medium and the long-term, the lack of adequate medical rooms to make the follow-up on specific pathologies, and the lack of specialized rooms and clinics. All these children, by the age sixteen, will suffer consequences of malformations, which may include issues of the cloaca, forked bone, esophageal substitutions, vaginal agenesis, orchiectomy, constipation, urinary and fecal incontinence, ischemic colitis, eosinophilic esophagitis, biliary reflux, Barrett's disease, pulmonary hypertension, chest wall deformities, and several other secondary malignancies.
It is important to offer less pain, better and faster recovery, and the absence of big scars. But in this new paradigm, we, as pediatric surgeons, should also offer more consistent results such as the possibility of better fertility, lower risk of malignancy, organ repair and not only aesthetic results. We should offer family assistantship at the time of surgery Later on, we should assist those young teenagers full of worries and unknowns. Finally, we should aid those adults worried about their physical and sanitary conditions, which are unworthy or insufficient to face their daily life.