IJCRR - Vol 10 Issue 04, February
Date of Publication: 17-Feb-2018
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Reflection of Syrian Refugees to Pediatric Surgery
Author: Metin Gunduz, Tamer Sekmenli, Ilhan Ciftci
Abstract:Objective: Migration is an emergency in all aspects. Since the war began many of Syrian refugees were treated in our country. We aimed to evaluate pediatric surgical outcomes of these children in a tertiary center in Turkey
Design: A retrospective study is reported
Setting: Patients in present study were treated in atertiary hospital
Subjects: Pediatric Syrian refugees
Main Outcome Measure: Syrian refugees who were operated at the Pediatric Surgery Department of our hospital between June 2014 and November 2017 were evaluated retrospectively. Demographic data, diagnosis, and treatment were recorded.
Results: We operated twenty male and eight female patients under general anesthesia. 8 (%28.6) of them had newborn pathologies, 5 (%17.9) had inguinal pathology, 3 (%10.8) had tumor, 3 (%10.8) had urological disorders, 5 (%17.9) had gastrointestinal pathology, 1 (%3.5) had lymphangioma, 1 (%3.5) had nux diaphragmatic hernia, 1 (%3.5) had bronchoscopy for evaluating tracheoesophageal fistula, and 1 (%3.5) was operated due to trauma. Patients died due to trauma and mutiple congenital anomalies. Others were treated succesfully.
Conclusions: Wars and natural disaster effects humans and especially children. They have to leave their countries and move to neighbouring countries. By this study we wanted to draw attention and rise awareness on this emergency. Like the pediatric surgeons in the border, all the pediatric surgeons in our country will continue to do their best with regard to these children.
Keywords: Syrian refugee, Children, Surgery
Wars affects soldiers and also elders, women and children. Since the war in Syria began in March 2011 Turkey is hosting 2,967,149 Syrian Refugees and 44.7 % of them are under age of 18 .Emerging situations like health, education, basic needs, protection, and social activity facilities is being provided by The Republic of Turkey. Thousands of seriously injured Syrians were brought to Turkey for emergency operations and intensive care. More than a million patient consultations for Syrian refugees were registered in out patient settings  . Although Konya is not a Sryian neighborhood province there is a great refugee movement and survey. In present study we aimed to evaluate the demographic and clinical characteristics of Syrian refugees to a pediatric surgery department of a tertiary care hospital.
Material and Methods
The study protocol was approved by the Selcuk University Medical Faculty Ethics Committee (2017/21-06/12/2017). The records of Syrian children those operated between June 2014 and October 2017 in Pediatric Surgery Department were retrospectively analyzed. Demographic data, diagnosis, and treatment were recorded. All patients had preoperative routine blood tests. If needed they had urine analysis, urinary ultrasonography, plain abdominal X-ray, computerized tomography, and magnetic resonance imaging. They received antibiotic prophylaxis excluding inguinal pathologies. All operations were performed under general anesthesia. Newborn patients were treated in newborn intensive care unit, some others in intensive care unit, and also in reanimation unit. After discharge some of the patients did not come back for follow up.
Twenty male and eight female patients were operated under general anesthesia. 8 (%28.6) of them had newborn pathologies, including anal atresia, corpus callosum hypoplasia, meningomyelocele, hydrocephalus, feeding intolerance, diaphragmatic hernia, gastric perforation, patent omphalomesenteric duct, meconium pseudocyst, again diaphragmatic hernia, and necrotizing enterocolitis . Divided colostomy, stamm gastrostomy, primary repair of diaphragmatic hernia, partiel gastric resection, resection ileo-ileal anastomosisi,, loop ieostomy, intestinal resection with divided jejunostomy, and primary repair with mesh was performed respectively. 5 (%17.9) had inguinal pathology as inguinal hernia (three of them), bilateral hydrocele, and incarcerated inguinal hernia. High ligation and hydrocelectomy was performed. 3 (%10.8) had tumor including Wilms tumor, abdominal rhabdomyosarkoma, and b cell lymphoma. Total-partiel excision, loop ileostomy, and chemoteraphy was applied. 3 (%10.8) had urological disorders like ureteropelvic junction obstruction, bilateral vesicoureteral reflux due to posterior uretral valv with chronic renal failure, and left vesicoureteral reflux. Anderson Hynes pyeloplasty, Mitrofanoff procedure and subureteral transurethral injection (STING) were performed. 5 (%17.9) had gastrointestinal pathology, including dysphagia and malnutrition due to cerebral palsy, hematemesis, feeding intolarence due to cardiomyopathy and pulmonary hypertension, feeding intolarence due to coanal atresia, and rupture of hepatic hydatid cyst. Stamm gastrostomy, gastroscopy, laparascopic gastrostomy, Stamm gastrostomy, and unroofing was performed respectively. Bleomycin injection was performed to lomber lymphangioma. Recurrence diaphragmatic hernia received patch repair. Splenectomy was pereformed to multitrauma patient. Bonchoscopy was performed to a patient that had aspiration pneumonia with tracheoesophageal fistula suspicion (Table 1). Those who had multitrauma and mutiple congenital anomalies were died. Others were treated succesfully and some of them are being treated by pediatric oncology and pediatric gastroenterology department.
Immigration due to wars is a serious problem that causes complex problems and affects human life. Women and children are the most aggrieved group. Turkey is a neighbour country to Syria and wounded refugees are being treated especially in border cities . Although Konya is not a Syrian neighborhood province there is a great refugee movement and survey as other cities in our country. This is the first study that evaluates immigrant children from Syria with pediatric surgical diseases.
There are several reports evaluating Syrian refugees. Heart disease in Syrian refugee children were reported by Al-Ammouri et al  .Late presentation and diagnosis, high rate of complications, suboptimal living conditions, lack of funding and high mortality rates were the major challenges of refugees in their study.
Newborns in present study had not any prenatal diagnosis. Clinical characteristics and pregnancy outcomes of Syrian refugees were reported by Erenel et al  . They showed that 41.3 % of Syrian patients did not receive antenatal care. Their findings support our results. One patient with multiple congenital anomaly including anal atresia and corpus callosum hypoplasia was died in our study. We do not have any knowledge about wheter parents of these children has exposure to chemical weapons. It was used in August 2013 as known  .
Turkish Government Ministry of Health has mended free healthcare for Syrian refugees. Pediatric surgical outpatients like inguinal hernia, hydrocele are being treated in State hospitals and not allowed to tertial centers. This explains the low number of patients with inguinal pathologies in our study.
In tumor group chemical weapon effects was seen in a patient from Aleppo with b cell lymphoma. Another one who had Wilms tumor had chemical waste doubt in drinking water. Although we are not sure we think that chemical weapons was used or being used in Syrian war.
Late presentation and diagnosis was the major challenge in patient with bilateral vesicoureteral reflux due to posterior uretral valv with chronic renal failure. Patients with gastrointestinal pathology, lomber lymphangioma, and recurrence diaphragmatic hernia had a successful treatment. Trauma was due to traffic accident in present study.
Injuried patients in Syria were transferred to emergency department of hospitals in border cities in Turkey so there is not any injuried patient such gunshot wounds, and burn in our study  . Differently from present study Çelikel et al evaluated demographical data and injury characteristics of Syrian children who were wounded in Syria Civil War and died while being treated in Turkey  . Children mostly died of head and neck injuries predominantly caused by bombing attacks and autopsies of them revealed fatal intracranial hemorrhages and parenchymal injuries in their study. Similarly patients with cranial gunshot wounds in the Syrian civil war were analysed by Aras et al  but only 8.6% of them were pediatric patients. The orphan children of Syria are at high risk of developing mental health disorders due to traumatic experiences, adjustment difficulties, and loss . For reducing the morbidity and mortality associated with mental illness in this population, mental health interventions were offered. Similarly the prevalence of post-traumatic stress disorders in adult Syrian refugees living in camps in Lebnon was determinated. Refugees from Aleppo had significantly more post-traumatic stress disorders than those coming from Homes  .
Birth characteristics of Syrian refugees and Turkish citizens in Turkey was evaluated and cesarean delivery number, median neonatal birth weight, and gestational diabetes was significantly higher in Turkish citizens .
As reemerging infections measles, poliomyelitis, leishmaniasis, and multidrug-resistant tuberculosis were most frequently seen in Syrian refugees  . Multidrug-resistant gram-negative bacterial infections were seen with high incidence in gunshot or surgical wounds.
Limitation of this study may include a retrospective design and low number of patients. Despite these limitations present study is the first to investigate pediatric surgical patients among Syrian refugees. The international community has to be aware of this and assist Turkey’s efforts to provide adequate health care to Syrian refugees.
Wars and natural disaster effects humans and especially children. They have to leave their countries and move to neighbouring countries. By this study we wanted to draw attention and rise awareness on this emergency.
Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed.
There is no conflict of interest.
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