BOB Ped Surg 2023 - Rachel Livergant, WOFAPS - Presentation

My name is Rachel Livergant, and today I am honored to present our team's work titled postoperative morbidity and mortality in pediatric indigenous patients, a scoping review and meta analysis. A special thank you to my co-authors and the WOFAPS team for all their work and support on this project. Finally, I would like to respectfully acknowledge that this presentation is being recorded on Treaty 6 territory, the traditional land of the Cree, Anishnabe, Blackfoot, Meti, Dene, and Dakota Sue peoples. Surgical care is a growing need globally with surgical conditions accounting for over 33% of the global burden of disease. Indigenous peoples are an important yet grossly underserved population worldwide, notably in the Americas and Oceania. Indigenous children and adolescents living in Settler govern countries face some of the largest health inequities worldwide. However, current data on post-operative outcomes following surgery in pediatric indigenous patients remains limited and of poor quality. This scoping review aims to assess if and which inequities exist between surgical outcomes in pediatric indigenous and non-indigenous peoples on the American and oceanic continents with regards to post-operative complications, morbidities and mortality. This study was completed in compliance with Moose and Prisma SCR guidelines. The Pico criteria can be found below and included populations of indigenous pediatric patients from North America, South America, and Oceania that were experimental or observational studies with outcomes including post-operative morbidity and mortality. Following full text review and gray literature search, a total of 16 studies met inclusion criteria, of which 14 were included in the final meta analysis. Of the 14 studies that met our inclusion criteria, all were retrospective studies, eight of which were retrospective cross-sectional studies. A total of seven studies were based in Oceania, seven in North America, and none were based in South America. There were a total of six pediatric surgical specialties included, such as general surgery, urology, neurosurgery, ENT, cardiac surgery, and ophthalmology. Overall, no significant difference was observed in post-operative morbidity between indigenous and non-indigenous pediatric patients. This remained non-significant when segregated by either geographic location or type of post-operative complication. However, in one study examining long-term graph survival following renal transplantation, indigenous children had a three times higher risk of renal graph failure compared to non-indigenous children in Canada. The study found overall mortality was significantly higher for indigenous patients with an OR of 2.06. Similarly, 30-day mortality was significantly increased with an OR of 2.23. When stratified by geographic location, indigenous children in North America had a greater than three times higher odds of post operative mortality. In contrast, indigenous children from Oceania did not have a significant increase in surgical mortality. In the one study that examined five-year surgical survival, indigenous children in Canada had a two times lower survival than their non-indigenous counterparts following renal transplantation. Conversely, in a similar study comparing post liver transplantation survival for Aboriginal and Tori Straight Islander children, there was no significant difference in 1 through 15 year survival between the two groups. Six studies were included in the meta analysis of health system interactions. Indigenous patients had a non-significant increase in hospital readmissions post-operatively and increased average hospital length of stay. There was no significant difference in reoperation rates between indigenous and non-indigenous patients. Of note, one of the studies reporting on reoperation rates noted that Maui and Pacific Islander children received significantly less reoperations following failed strabismus repairs compared to non-indigenous children. The Newcastle Ottawa scale was used to assess quality of included studies. Majority of studies, 12 out of 14 were high risk of bias and low quality, while two studies were low risk of bias and good quality. The low quality of studies was mainly attributed to failure of studies to control for significant differences such as age, pre-existing comorbidities, and or sex in their analysis. In summary, this study has found that indigenous pediatric patients have a significantly increased mortality post-operatively. More notably, the study has also found that there is a high evidence of poor quality studies related to this topic. Based on the study's findings, we propose the need for further research and health system reforms that are appropriate for the indigenous context and enshrine in their models the need for multiprong solutions that respect the unique culture, experiences and needs of diverse indigenous communities worldwide. Thank you very much for the opportunity to present this work. If you have any questions, please do not hesitate to contact the authors.