Pediatric surgical practices in children under conflict and the case of Gaza after October 7

Year 2024, Volume: 29 Issue: Special Issue on Gaza, 38 - 51, 28.12.2024

Emre Çelik , Taner Kamacı

https://doi.org/10.21673/anadoluklin.1593801

Abstract

Aim: The health crisis resulting from Israel’s attacks on Gaza after October 7th, and the need for a comprehensive analysis of pediatric surgical practices in conflict zones, must be thoroughly addressed. The aim of this study is to describe the challenges encountered in providing pediatric surgical care under conditions of limited healthcare services.

Methods: A retrospective analysis was conducted on 31 pediatric cases that underwent surgical procedures at the Gaza European Hospital between March 18, 2024, and April 1, 2024. Data collected included the patients’ age, gender, place of residence, mode of admission, surgical indications, mechanism of injury, anesthesia details, shortages in medical supplies, and in-hospital morbidity and mortality rates. Continuous variables were expressed as mean ± standard deviation, while categorical variables were presented as counts (n) and percentages (%). The Chi-square test was used for the comparison of categorical variables.

Results: The mean age of the 31 cases included in the study was 5.86 years (ranging from 7 months to 14 years). During this period, 20 patients (64.5%) underwent pediatric surgical procedures due to war-related injuries, such as bombings and shrapnel wounds. Of the cases, 21 (67.7%) were displaced or forcibly relocated individuals, while 10 (32.3%) were local residents. The majority of cases involved polytrauma (9 cases, 29%) and intestinal perforation (9 cases, 29%). The most common surgical procedures included laceration repair for polytrauma resulting from bombings or debris-related injuries (6 cases, 19%), primary repair of intestinal perforation via laparotomy for shrapnel-induced injuries (4 cases, 12%), intestinal resection and anastomosis via laparotomy (4 cases, 12%), and laparoscopic inguinal hernia repair (4 cases, 12%). Postoperative sepsis occurred in only one case (3.2%), which subsequently resulted in in-hospital mortality (3.2%).

Conclusion: Local healthcare providers and volunteer pediatric surgeons working with international humanitarian organizations have played a vital, life-saving role in addressing both the injuries inflicted on children due to Israeli attacks and the broader humanitarian needs. The surgical interventions performed on 31 cases demonstrate that even under challenging circumstances, highly limited pediatric surgical care and services can be delivered. Moreover, these cases highlight the critical importance and superiority of conducting pediatric surgical interventions under the expertise of specialized professionals.

Keywords

Conflict, emergency treatment, first aid, Gaza, pediatrics

Çatışma altındaki çocuklarda pediatrik cerrahi uygulamaları ve 7 Ekim sonrası Gazze örneği

Abstract

Amaç: 7 Ekim sonrası İsrail’in Gazze’ye başlattığı saldırılar sonucunda yaşanan sağlık krizinin ve çatışma bölgelerinde çocuklara yönelik pediatrik cerrahi uygulamalarının kapsamlı bir şekilde ele alınması gerekmektedir. Bu çalışmanın amacı, pediatrik cerrahi uygulanan olgularda sınırlı sağlık hizmeti sunumunda karşılaşılan zorlukları açıklamaktır.

Yöntemler: 18 Mart 2024’ten 1 Nisan 2024’e kadar Gazze Avrupa Hastanesi’nde pediatrik cerrahi uygulanan 31 olgu retrospektif olarak incelendi. Pediatrik olguların yaş, cinsiyet, hasta yerleşim yeri, başvuru şekli, cerrahi işlemin endikasyonu, yaralanma mekanizması, anestezi, tıbbi malzeme eksikliği ve hastane içi morbidite, mortalite verileri kaydedildi. Sürekli değişkenler ortalama ve standart sapma ile kategorik değişkenler sayı (n) ve yüzde (%) olarak ifade edilmiştir. Kategorik değişkenlerin karşılaştırmasında Ki-Kare testi kullanılmıştır.

Bulgular: Çalışmaya dâhil edilen 31 vakanın ortalama yaşı 5,86'ydı. Bu süre içinde hastaların 20’sine (%64,5) bombalanma, şarapnel parçasıyla yaralanma gibi savaş yaralanmaları nedeniyle pediatrik cerrahi işlem uygulanmıştır. Olguların 21’i (%67,7) yerinden edilmiş, göçe zorlanmış vatandaş, 10’u (%32,3) ise yerel idi. Olguların büyük çoğunluğu politravma (9, %29), barsak perforasyonu (9, % 29) vakalarıydı. Bombalanmaya ya da enkazda yaralanmaya bağlı politravma hastalarının laserasyon onarımı (6, %19), şarapnel parçasıyla yaralanmaya bağlı barsak perforasyonu için laparotomiyle barsak perforasyonu primer onarımı (4, %12), laparotomiyle barsak perforasyonu rezeksiyon ve anastomoz (4, %12), laparoskopik inguinal herni onarımı (4, %12) en yaygın işlemlerdi. Sadece bir olguda ameliyat sonrası sepsis gelişti (%3,2) ve hastada sonrasında hastane içi ölüm (%3,2) görülmüştür.

Sonuç: Yerel sağlık hizmeti sağlayıcıları ve uluslararası insani yardım kuruluşlarına bağlı çalışan gönüllü çocuk cerrahları hem İsrail’in saldırıları nedeniyle çocuklarda meydana gelen yaralanmalar hem de insani ihtiyaçlar için değerli, hayat kurtarıcı rol üstlenmişlerdir. Cerrahi müdahale uygulanan 31 olgu zorlu koşullar altında bile olsa son derece sınırlı pediatrik cerrahi hizmeti ve bakımı verilmekte olduğunu ve aynı zamanda pediatrik cerrahi müdahalelerin uzmanlaşmış kişiler eliyle yapılmasının üstünlüğünü göstermektedir.

Keywords

Acil tedavi, çatışma, Gazze, ilk yardım, pediatri

References

• Frounfelker RL, Islam N, Falcone J, et al. Living through war: Mental health of children and youth in conflict-affected areas. Int Rev Red Cross. 2019;101(911):481–506.
• Haverkamp FJC, van Gennip L, Muhrbeck M, Veen H, Wladis A, Tan ECTH. Global surgery for paediatric casualties in armed conflict. World J Emerg Surg. 2019;14:55.
• World Health Organization (WHO). WHO analysis highlights vast unmet rehabilitation needs in Gaza. October 12, 2024. Erişim tarihi: 20 Kasım 2024. Erişim adresi: https://www.emro.who.int/opt/news/who-analysis-highlights-vast-unmet-rehabilitation-needs-in-gaza.html.
• Reliefweb. Reported impact snapshot | Gaza Strip, 12 November 2024 at 15:00. November 12, 2024. Erişim tarihi: 20 Kasım 2024. Erişim adresi: https://reliefweb.int/report/occupied-palestinian-territory/reported-impact-snapshot-gaza-strip-12-november-2024-1500.
• Boyden J. Children’s experience of conflict-related emergencies: Some implications for relief policy and practice. Disasters. 1994;18(3):254–67.
• United Nations Children’s Fund (UNICEF). Çocuk Haklarına Dair Sözleşme. Erişim tarihi: 20 Kasım 2024. Erişim adresi: https://www.unicef.org/turkiye/%C3%A7ocuk-haklar%C4%B1na-dair-s%C3%B6zle%C5%9Fme
• Wild H, Stewart BT, LeBoa C, Stave CD, Wren SM. Pediatric casualties in contemporary armed conflict: A systematic review to inform standardized reporting. Injury. 2021;52(7):1748-56.
• Taha AM, Sabet C, Nada SA, Abuzerr S, Nguyen D. Addressing the mental health crisis among children in Gaza. Lancet Psychiatry. 2024;11(4):249-50.
• Trudeau MO, Baron E, Hérard P, et al. Surgical Care of Pediatric Patients in the Humanitarian Setting: The Médecins Sans Frontières Experience, 2012-2013. JAMA Surg. 2015;150(11):1080-5.
• Burd RS, Jensen AR, VanBuren JM, et al. Long-Term Outcomes after Pediatric Injury: Results of the Assessment of Functional Outcomes and Health-Related Quality of Life after Pediatric Trauma Study. J Am Coll Surg. 2021;233(6):666-675.e2
• Canadian Broadcasting Corporation. UN official describes "immense relief" as water, food arrive in north Gaza amid truce. 26 Kas 2023. Erişim tarihi: 22 Kasım 2024. Erişim adresi: https://www.cbc.ca/news/world/un-northern-gaza-1.7040635.
• Aljazeera. Israel war on Gaza updates: Children dying ‘in every possible way’. January 6, 2024. Erişim tarihi: 22 Kasım 2024. Erişim adresi: https://www.aljazeera.com/news/liveblog/2024/1/6/israel-war-on-gaza-live-israeli-forces-raid-occupied-west-bank-towns?update=2601163.
• Timotija F. UN warns of viruses spreading in Gaza. January 19, 2024. The Hill. Erişim tarihi: 22 Kasım 2024. Erişim adresi: https://thehill.com/policy/international/4417536-gaza-un-warns-viruses-spreading-poor-conditions/#:~:text=After%20finishing%20a%20three%2Dday,before%20the%20escalation%20in%20hostilities.
• UNICEF official slams world’s ‘shocking inaction’ on impending famine in Gaza. Aljazeera. March 19, 2024. Erişim tarihi: 22 Kasım 2024. Erişim adresi: https://www.aljazeera.com/news/liveblog/2024/3/19/israels-war-on-gaza-live-israel-holds-al-jazeera-reporter-for-12-hours?update=2782667.
• Israel’s war on Gaza updates: US expresses doubt over Israel’s Rafah attack. Aljazeera. February 8, 2024. Erişim tarihi: 22 Kasım 2024. Erişim adresi: https://www.aljazeera.com/news/liveblog/2024/2/8/israels-war-on-gaza-live-us-says-space-for-truce-deal-israel-vows-war?update=2692304
• Farge E. Israel violated global child rights treaty in Gaza, UN committee says. September 19, 2024. Erişim tarihi: 22 Kasım 2024. Erişim adresi: https://www.reuters.com/world/middle-east/israel-violated-global-child-rights-treaty-gaza-un-committee-says-2024-09-19/.
• World Health Organization (WHO). oPt Emergency Situation Update. November 12, 2024. Erişim tarihi: 24 Kasım 2024. Erişim adresi: https://www.emro.who.int/images/stories/Sitrep_50b.pdf?ua=1
• United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA). UNRWA Situation Report 148: Situation Gaza Strip and West Bank including East Jerusalem. November 20, 2024. Erişim tarihi: 22 Kasım 2024. Erişim adresi: https://www.unrwa.org/resources/reports/unrwa-situation-report-148-situation-gaza-strip-and-west-bank-including-east-jerusalem.
• Blanchet K, Najem M, Shadid L, et al. Rebuilding the health sector in Gaza: alternative humanitarian voices. Confl Health. 2024;18(1):42.
• Anadolu Agency (AA). Gazze'de gönüllü hizmet veren Türk cerrah Kamacı'dan meslektaşlarına çağrı. March 28, 2024. Erişim tarihi: 26 Kasım 2024. Erişim adresi: https://www.aa.com.tr/tr/dunya/gazzede-gonullu-hizmet-veren-turk-cerrah-kamacidan-meslektaslarina-cagri/3177121.
• Edirne Y. Gazze'de gönüllü hizmet veren Türk cerrah Kamacı yaşadıklarını anlattı. June 7, 2024. Erişim tarihi: 26 Kasım 2024. Erişim adresi: https://www.aa.com.tr/tr/ayrimcilikhatti/ayrimcilik/gazzede-gonullu-hizmet-veren-turk-cerrah-kamaci-yasadiklarini-anlatti/1820458.
• Mohammad L. Children make up nearly half of Gaza's population. Here's what it means for the war. October 19, 2023. Erişim tarihi: 23 Kasım 2024. Erişim adresi: https://www.npr.org/2023/10/19/1206479861/israel-gaza-hamas-children-population-war-palestinians.
• Euro-Med Human Rights Monitor. New Report: 91% of Gaza children suffer from PTSD after the Israeli attack. June 2, 2021. Erişim tarihi: 23 Kasım 2024. Erişim adresi: https://euromedmonitor.org/en/article/4497/New-Report:-91%25-of-Gaza-children-suffer-from-PTSD-after-the-Israeli-attack.
• International Rescue Committee. Medical Aid for Palestinians and International Rescue Committee Emergency Medical Team report serious malnutrition and harrowing injuries in Gaza hospital. January 5, 2024. Erişim tarihi: 23 Kasım 2024. Erişim adresi: https://www.rescue.org/press-release/medical-aid-palestinians-and-international-rescue-committee-emergency-medical-team.
• Muthumani A. Safeguarding children through pediatric surgical care in war and humanitarian settings: a call to action for pediatric patients in Gaza. World J Pediatr Surg. 2024;7(1):e000719.
• Medical Aid for Palestinians. Hours left to save Gaza's health system from total collapse. October 25, 2023. Erişim tarihi: 26 Kasım 2024. Erişim adresi: https://www.map.org.uk/news/archive/post/1528-hours-left-to-save-gazas-health-system-from-total-collapse-press-release.
• Palestinian Doctors Union. The joint delegation of PalMed and Rahma Worldwide Foundation has safely arrived in Gaza. March 18, 2024. Erişim tarihi: 26 Kasım 2024. Erişim adresi: https://www.palmedeurope.org/en/deligation-4-en/
• Aguirre AS, Rojas K, Torres AR. Pediatric traumatic brain injuries in war zones: a systematic literature review. Front Neurol. 2023;14:1253515.
• Reliefweb. Gaza: 10,000 children killed in nearly 100 days of war. January 11, 2024. Erişim adresi: https://reliefweb.int/report/occupied-palestinian-territory/gaza-10000-children-killed-nearly-100-days-war?lang=ru.
• McGreal I. Israeli weapons packed with shrapnel causing devastating injuries to children in Gaza, doctors say. July 11, 2024. Erişim tarihi: 26 Kasım 2024. Erişim adresi: https://www.theguardian.com/world/article/2024/jul/11/israeli-weapons-shrapnel-children-gaza-injured?CMP=twt_b-gdnnews.
• Khaled F. A baby evacuated from Gaza lost an eye and most of his family in the war. ABC News. 23 Ağustos 2024. Erişim tarihi: 26 Kasım 2024. Erişim adresi: https://web.archive.org/web/20240908131029/https://abcnews.go.com/International/wireStory/baby-evacuated-gaza-lost-eye-family-war-113091264.
• Human Rights Watch. “They Destroyed What Was Inside Us”. 30 Eylül 2024. Erişim tarihi: 26 Kasım 2024. Erişim adresi: https://www.hrw.org/report/2024/09/30/they-destroyed-what-was-inside-us/children-disabilities-amid-israels-attacks-gaza.
• UNICEF. Average of at least 16 children killed or injured in Ukraine every week as escalation of war nears 1,000 days. 18 Kasım 2024. Erişim tarihi: 26 Kasım 2024. Erişim adresi: https://www.unicef.org/press-releases/average-least-16-children-killed-or-injured-ukraine-every-week-escalation-war-nears.
• Dünya Sağlık Örgütü (DSÖ). Variant type 2 poliovirus isolated from sewage samples in Gaza. 21 Temmuz 2024. Erişim tarihi: 27 Kasım 2024. Erişim adresi: https://www.emro.who.int/opt/news/variant-type-2-poliovirus-isolated-from-sewage-samples-in-gaza.html.
• Dünya Sağlık Örgütü (DSÖ). First phase of polio campaign concludes successfully in Gaza. 4 Eylül 2024. Erişim tarihi: 27 Kasım 2024. Erişim adresi: https://www.who.int/news/item/04-09-2024-first-phase-of-polio-campaign-concludes-successfully-in-gaza.
• Dünya Sağlık Örgütü (DSÖ). Second round of polio campaign in Gaza completed amid ongoing conflict and attacks: UNICEF and WHO. 6 Kasım 2024. Erişim tarihi: 27 Kasım 2024. Erişim adresi: https://www.who.int/news/item/06-11-2024-second-round-of-polio-campaign-in-gaza-completed-amid-ongoing-conflict-and-attacks--unicef-and-who.
• Médecins Sans Frontières (MSF). Lives of children and newborns put at risk by living conditions in Gaza. 22 Kasım 2024. Erişim tarihi: 27 Kasım 2024. Erişim adresi: https://www.msf.org/lives-children-and-newborns-put-risk-living-conditions-gaza.
• Irfan B, Luu I, Hamawy A, et al.. Combating Infections Under Siege: Healthcare Challenges Amidst the military assault in Gaza. World Medical & Health Policy. 2024; 1–26.
• UNICEF. Facing life in the Gaza Strip with a new disability. 21 Aralık 2023. Erişim tarihi: 27 Kasım 2024. Erişim adresi: https://www.unicef.org/sop/stories/facing-life-gaza-strip-new-disability.
• Anadolu Ajansı (AA). Hospital in northern Gaza struggles to operate due to supply shortages amid Israeli attacks. 6 Kasım 2024. Erişim tarihi: 27 Kasım 2024. Erişim adresi: https://www.aa.com.tr/en/middle-east/hospital-in-northern-gaza-struggles-to-operate-due-to-supply-shorta. ges-amid-israeli-attacks/3386545.
• Reliefweb. Humanitarian Situation Update 233- Gaza Strip. 29 Ekim 2024. Erişim tarihi: 27 Kasım 2024. Erişim adresi: https://reliefweb.int/report/occupied-palestinian-territory/humanitarian-situation-update-233-gaza-strip-enarhe.
• Pulvirenti R, Gortan M, Cumba D, Gamba P, Tognon C. Pediatric Surgery and Anesthesia in Low-Middle Income Countries: Current Situation and Ethical Challenges. Front Pediatr. 2022;10:908699.
• British Red Cross. Famine looms in Gaza, and nowhere is safe for civilians. Erişim tarihi: 27 Kasım 2024. Erişim adresi: https://www.redcross.org.uk/stories/disasters-and-emergencies/world/whats-happening-in-gaza-humanitarian-crisis-grows.
• UNICEF. Children in Gaza need life-saving support. Erişim tarihi: 27 Kasım 2024. Erişim adresi: https://www.unicef.org/emergencies/children-gaza-need-lifesaving-support.
• Uluslararası Kurtarma Komitesi. The IRC reacts to latest IPC alert: Famine is imminent in parts of Gaza. 18 Kasım 2024. Erişim tarihi: 27 Kasım 2024. Erişim adresi: https://www.rescue.org/eu/press-release/irc-reacts-latest-ipc-alert-famine-imminent-parts-gaza.
• Dünya Sağlık Örgütü (DSÖ). Statement by WHO Regional Director Dr Hanan Balkhy on visit to the occupied Palestinian territory. 12 Ekim 2024. Erişim tarihi: 27 Kasım 2024. Erişim adresi: https://www.emro.who.int/media/news/statement-by-who-regional-director-dr-hanan-balkhy-on-visit-to-the-occupied-palestinian-territory.html.
• Birleşmiş Milletler İnsani Yardım Koordinasyon Ofisi. 26 Kasım 2024. Erişim tarihi: 27 Kasım 2024. Erişim adresi: https://www.ochaopt.org/content/reported-impact-snapshot-gaza-strip-26-november-2024.
• Reliefweb. Humanitarian Situation Update 241 | Gaza Strip. 26 Kasım 2024. Erişim tarihi: 27 Kasım 2024. Erişim adresi: https://reliefweb.int/report/occupied-palestinian-territory/humanitarian-situation-update-241-gaza-strip.
• Trudeau MO, Rothstein DH. Injuries and surgical needs of children in conflict and disaster: From Boston to Haiti and beyond. Semin Pediatr Surg. 2016;25(1):23-31.
• Human Rights Watch. Gaza: Israeli Attacks Devastate Lives of Children with Disabilities. 30 Eylül 2024. Erişim tarihi: 27 Kasım 2024. Erişim adresi: https://www.hrw.org/news/2024/09/30/gaza-israeli-attacks-devastate-lives-children-disabilities.