Before patients are scheduled for surgery, they undergo a standardized process of screening where a brief medical, surgical, and family history is obtained and a focused physical examination is per-formed. A staff of Pediatricians initiates the encounter, pass the patient to the Surgeons who will map out the surgical plan, then a patient list is generated. On the day of the surgery, the Anesthesiologists perform a quick pre-anesthesia check or survey before the patient ends up on the operating table. Sounds simple and straightforward, right? Yes, and no.
THE FOLLOWING ARE PAGES GUIDING PRINCIPLE:
The general state of health of the patient takes the top priority. After all, we perform elective surgeries. Complementing the physical examinations are the minimal laboratory works or tests and a chest X-ray. We make sure the complete blood counts are “normal”. We will not clear for surgery a patient who is anemic, may have an infection or may have bleeding tendencies. A chest X ray is ordered, with or without pulmonary symptoms.
The type of surgical anomaly is important as to the timing of the surgery. A cleft lip can be repaired at any age, while a cleft palate needs to be corrected, preferably before the age of critical pho-nation skills are acquired, to allow for intelligible speech, and for optimal nutrition. We repair the cleft lip first, then the cleft palate the following year. Very rarely do we per-form combination cleft lip and cleft palate repairs.
Having stated the above, age matters too, and we prioritize younger children, from infancy to preadolescence. Almost all children younger than 13 years of age are operated on. Teenagers, young adults and mature adults who present with cleft palate are done only on a case-to-case basis, at the discretion of individual surgeons, and in a collaborative agreement with the Medical/Pediatric and Anesthesia staff.
Once an acute infection is detected on physical exam and on laboratory blood tests, we may opt to treat and reschedule the patient for surgery at a later date that week, after a re-assessment to be cleared for surgery. The routine chest X-ray may reveal a pneumonia and will have to be treated with antibiotics, re-assessed later that week and may get cleared for surgery. Additionally, an asymptomatic patient may have a radio graphic diagnosis of Primary Complex TB. This has been a source of controversy to other surgical mission groups in the Philippines and it requires some clarification.
REGARDING PRIMARY COMPLEX:
Tuberculosis (TB) afflicts children throughout the world in a major way, the Philippines included. Its exact incidence or prevalence is not known in the Philippines because of the inconsistent manner of identifying or diagnosing, and treating the disease.
Childhood TB in the Philippines is hard to prove. Because of the BCG given to children, the usual TB skin test (PPD) is inaccurate or unreliable. The gold standard test for TB, Quantiferon TB Gold, is hard to interpret in children below 4 or 5 years, more so in children below 2 years of age. Therefore, chest X-ray is the go-to test, most of the times, especially in asymptomatic children who are exposed to TB, or with a history of symptoms that suggests TB. It is also very difficult to collect sputum in children to prove the diagnosis of Pulmonary TB. Close to 50% of childhood TB is asymptomatic.
Primary complex becomes the X-ray diagnosis of TB in some of these children. Oftentimes, the diagnosis of Primary Complex is based on suspicion or what we call “high index of suspicion”, with or with-out respiratory symptoms like cough (productive), fever, night sweats, etc. Primary complex, with or with-out symptoms, is not a contraindication to do surgery, especially in the case of cleft lip or cleft palate surgery.
The treatment of Primary Complex or TB among our surgical patients is not our, i.e. PAGES, responsibility, and therefore needs to be referred to the health department, for several reasons: a) the local health department needs to make sure that after the TB work up is done, and the diagnosis is confirmed, that treatment gets started and completed; b) the treatment of Primary Complex may take 6-9 months to complete; c) the follow up after treatment of these patients is a must; d) contacts of the diagnosed TB patients have to be pursued and treated appropriately; e) the choice of anti-TB medications is based on the epidemiology of Multi-Drug Resistant (MDR)TB in the Philippines.
Children this young (especially those without symptoms), the ones that we operate on – infants and toddlers and even some older children, have low TB (bacilli) load. Primary complex in infants and children poses no risk to themselves, during surgery, nor to others.