Pediatric neurosurgery without pediatric neurosurgeons: a comparison of outcomes of pediatric brain tumor resections in Pakistan with a national US surgical database

Purpose: There are currently no specialized pediatric neurosurgeons in Pakistan. The extent to which this impacts the outcomes of children undergoing surgery for neurological conditions in the country is unclear. We aimed to investigate whether outcomes of brain tumor resections in children at our high-volume center in Pakistan were comparable to those performed by pediatric neurosurgeons in a large, validated US surgical database. Methods: A multi-center collaborative collected clinical data on supratentorial and infratentorial craniotomy procedures (SC and IC, respectively) for malignant brain tumors in children < 18 years at a single center in Pakistan from 2015 to 2022. Similarly, the National Surgical Quality Improvement Program-Pediatric (NSQIP-P) 2021 dataset was queried to extract a comparable cohort of patients. Rates of adverse outcomes and quality metrics were compared between the groups using appropriate statistical tests. Results: We collected data on 105 Pakistan patients and 570 NSQIP-P patients. Patient demographics were similar for both groups. A total of 350 and 325 children underwent SC and IC, respectively. Postoperatively, children in the Pakistan cohort had worse neurological outcomes, including higher rates of postoperative seizures (SC, p < 0.001; IC, p = 0.003) and focal neurological deficits (SC, p = 0.003; IC, p < 0.001). Furthermore, Pakistani children undergoing SC had higher rates of postoperative mortality (p = 0.002), surgical site infections (p = 0.015), and deep wound infections (p = 0.027), while those undergoing IC had higher rates of unplanned intubations (p < 0.001) and prolonged postoperative mechanical ventilation > 48 h (p = 0.004) compared to their US counterparts captured in NSQIP-P data. Conclusion: Despite the availability of neuroimaging, cancer therapeutics, and intensive care at our center, children undergoing brain tumor resections had worse outcomes than their US counterparts. There is likely a need for specialized pediatric neurosurgical health services to improve outcomes of children undergoing complex neurosurgical procedures in Pakistan.