title: Elective pediatric surgical care in a forward deployed setting: What is feasible vs. what is reasonable.
abstract: OBJECTIVE
  To describe the scope and outcomes of elective pediatric surgical procedures performed during combat operations.
  
  
  BACKGROUND
  The care of patients in Operation Enduring Freedom (OEF) includes elective humanitarian surgery on Afghan children. Unlike military reports of pediatric trauma care, there is little outcome data on elective pediatric surgical care during combat operations to guide treatment decisions.
  
  
  METHODS
  All elective surgical procedures performed on patients≤16years of age from May 2012 through April 2014 were reviewed. Procedures were grouped by surgical specialty and were further classified as single-stage (SINGLE) or multi-stage (MULTI). The primary endpoint was post-operative complications requiring further surgery, and the secondary endpoint was post-operative follow up.
  
  
  RESULTS
  A total of 311 elective pediatric surgical procedures were performed on 239 patients. Surgical specialties included general surgery, orthopedics, otolaryngology, ophthalmology, neurosurgery and urology. 178 (57%) were SINGLE while 133 (43%) were MULTI. Fifteen patients required 32 procedures for post-operative complications. Approximately half of all procedures were performed as outpatient surgery. Median length of stay for inpatient was 2.2days, and all patients survived to discharge. The majority of patients returned for outpatient follow-up (207, 87%), and 4 patients (1.7%) died after discharge.
  
  
  CONCLUSIONS
  Elective pediatric surgical care in a forward deployed setting is feasible; however, limitations in resources for perioperative care and rehabilitation mandate prudent patient selection particularly with respect to procedures that require prolonged post-operative care. Formal guidance on the process of patient selection for elective humanitarian surgery in these settings is needed.
authors.affiliation: Department of Surgery, David Grant Medical Center, 101 Bodin Circle, Travis Air Force Base, California 94535; Department of Surgery, UC Davis Medical Center, 2315 Stockton Blvd. Sacramento, California 95817; Department of Surgery, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, Maryland 20814. Electronic address: lucas.neff.2@us.af.mil.
authors.forename: Lucas P
authors.initials: LP
authors.lastname: Neff
authors.affiliation: Department of Surgery, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, Maryland 20814; Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, 3400 Spruce St, Philadelphia, Pennsylvania 19104. Electronic address: jeremy.cannon@uphs.upenn.edu.
authors.forename: Jeremy W
authors.initials: JW
authors.lastname: Cannon
authors.affiliation: Department of Pediatrics, San Antonio Military Medical Center, 3551 Roger Brooke Dr. JBSA, Fort Sam Houston, Texas 78234. Electronic address: kathryn.charnock@us.af.mil.
authors.forename: Kathryn M
authors.initials: KM
authors.lastname: Charnock
authors.affiliation: Department of Surgery, UC Davis Medical Center, 2315 Stockton Blvd. Sacramento, California 95817. Electronic address: diana.farmer@ucdmc.ucdavis.edu.
authors.forename: Diana L
authors.initials: DL
authors.lastname: Farmer
authors.affiliation: Department of Pediatrics, San Antonio Military Medical Center, 3551 Roger Brooke Dr. JBSA, Fort Sam Houston, Texas 78234; Department of Pediatrics, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, Maryland 20814. Electronic address: matthew.a.borgman.mil@mail.mil.
authors.forename: Matthew A
authors.initials: MA
authors.lastname: Borgman
authors.affiliation: Department of Surgery, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, Maryland 20814; Department of Surgery, Naval Medical Center Portsmouth, 620 John Paul Jones Circle, Portsmouth, Virginia 23708. Electronic address: robert.l.ricca.mil@mail.mil.
authors.forename: Robert L
authors.initials: RL
authors.lastname: Ricca
mesh_terms: D055826:Afghan Campaign 2001-; D000346:Afghanistan; D000533:Altruism; D002648:Child; D002675:Child, Preschool; D017558:Elective Surgical Procedures / Q000379:methods / Q000706:statistics & numerical data*; D005240:Feasibility Studies; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008887:Military Medicine / Q000379:methods / Q000706:statistics & numerical data*; D017063:Outcome Assessment, Health Care; D010372:Pediatrics / Q000379:methods / Q000706:statistics & numerical data*; D011183:Postoperative Complications / Q000453:epidemiology / Q000601:surgery; D012189:Retrospective Studies; D013043:Specialties, Surgical / Q000379:methods / Q000706:statistics & numerical data*; D014481:United States
keywords: Afghanistan; Elective surgery; Global surgery; Humanitarian; Military