第38回日本小児神経外科学会
The 38th Annual Meeting of the Japanese Society for Pediatric Neurosurgery

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第1日目、6月4日(金)A 会場(3階 メインホール)12:00〜12:30

ランチョンセミナー 1: Alain Pierre-Kahn

座長: 堀 智勝

LS1

Pediatric Neurosurgery: History, Development, Educational System In France Experience of Necker Enfants Malades Hospital

Alain Pierre-Kahn Paris

Former, Professor of Necker Enfants-Malades Hospital

How a specialty comes to be

Several pre-requisites are necessary before a specialty can be recognized as such: 1) an absolute need 2) recognition of this need by the medical community and the political power i.e. by those who will create the means of its development 3) determination on a national basis of the localization, number, size, and environment of the structures to create. 4) formation, education and recruitment of medical and para-medical specialists 5) creation of an official status on it.

Pediatric neurosurgery: an absolute need

It is now admitted that a neurosurgical child differs from an adult one by his physiology, pathology, symptoms, reaction to treatments, goals of treatments and that he needs specific cares and environment offering specialized neurosurgeons, anesthetists, physicians and nurses. Pediatric neurosurgery is recognized by the WFNS and the boards in US, UK and France and considered as a worldwide health problem accounting for 20% of the whole neurosurgical activity in developed countries, 50% in under-developed countries and 80% in Africa.

Start and development of Pediatric Neurosurgery in France and Paris

In 1960, independent pediatric neurosurgery departments had already been created in Boston, Toronto and Chicago but none existed in France. Discussions between the neurosurgeons of Paris and their administration began in 1960 but general neurosurgeons, reluctant to lose part of their practice, didn’t push very strongly. The first structure of pediatric neurosurgery in France was finally created in 1970 in Paris rapidly followed by Marseille and Lyon. In Paris, the structure opened in 1971 in the hospital of Necker-Enfants Malades (NEM) under the authority of JF Hirsch. However, beds of pediatric neurosurgery still coexisted within each of the adult neurosurgery services. These beds disappeared in 1994, giving then to NEM hospital the quasi monopoly of the pediatric neurosurgery for Paris and its region (13 millions inhabitants).

The structures

Departments or units?
Two types of structures coexist in France:

1) Independent departments, on the basis of 1 per 5 millions inhabitants, highly qualified, managed by a full-time staff of pediatric neurosurgeons on the basis of 1 senior per 3 millions inhabitants, running their own budget. They act as reference centers, receiving patients from their own region but also eventually from others in the case of rare or difficult pathologies. They also have to promote the specialty through education, formation, research and publications. There are 4 such services in France, the major one being in Paris whom basin of population is of 13 millions people. A department of pediatric neurosurgery has advantage to be within a building housing all types of surgery and ICUs, maternity, neonatology, radiology, emergency wards as well as some pediatric specialties as neurology. Such a building is on the way to be achieved in NEM.

2) Units of pediatric beds of neurosurgery localized either in pediatric departments or in adult general neurosurgery services. Fitted for low-density populated regions, they are dispatched in several middle-size cities, acting as proximity centers for emergency cases and current pathologies. One or two committed pediatric neurosurgeons, anesthesiologists and nurses manage these units. The neurosurgeon(s) in charge of the unit must have been trained in a reference center of pediatric neurosurgery a minimum of 1 year and must have followed the complete cycle of European courses of pediatric neurosurgery. The staff must include a pediatrician and at least one nursery nurse. Pediatric beds must be apart from adult ones but in vicinity with a service of general neurosurgery. If necessary, the immediate postoperative transfer of a child to the general intensive care unit must be rapidly feasible. This unit must be equipped with pediatric beds and monitors adapted to any age. The activity of a unit of pediatric neurosurgery must be of a minimum of 100 surgeries per year.

In the case of emergency and in the absence of a unit of pediatric neurosurgery, primary cares must be done in the general neurosurgery service, the child being discharged later on in the pediatric department.

Such an organization has obvious advantages from a medical point of view but the distinction between units and reference centers raises difficult problems due to both the reluctance of local neurosurgeons to transfer their patients and social disagreement to send a child sometimes far away from his home.

General hospital or pediatric hospital?

Departments of pediatric neurosurgery must be within pediatric hospitals to take advantage of the presence of connected pediatric specialists, mainly anesthesiologists, radiologists, surgeons, pediatricians, and nurses.

Units, linked to a service of general neurosurgery, are usually within a general hospital.

Size of a structure of Pediatric Neurosurgery

The density of population around the structure to create should dictate its optimal size but this can be difficult for different and opposite reasons: on the one hand, shorter and shorter hospital stays, a declining demography and an increasing activity in private clinics plus a larger number of children referred from other cities or from abroad as the department’s reputation grows up.

For Paris, a first estimation of the needs was 0.01 bed per 1000 inhabitants which actually revealed much too high. The nowadays estimation is 0.003 bed per 1000, or 3 beds per million inhabitants. The 42 beds of the NEM department (including the 14 of the ICU) fit well with the 13 millions inhabitants of Paris and its region. NEM is responsible for 30% of the whole pediatric neurosurgery in France. In 2002, 3150 patients were hospitalized of whom 1280 were operated on (40,8%). Trauma, cranio-facial malformations, tumors and hydrocephalus accounted for respectively 25%, 20%, 16% and 15% of the cases; 47% of the tumors needed surgery (n=242).

The minimal number of beds for a department should not be less than 15, meaning that the basin of population for such a structure cannot be less than 5 millions. Smaller, a department would not be viable as such: recruitment and experience would be insufficient, would prevent neurosurgeons from being totally devoted to pediatric neurosurgery and would not permit sufficiently large series of patients to influence therapeutic protocols and provide statistically significant results.

Units of a few pediatric beds are the only appropriate structure in the case of low-density population.

The medical staff

The French authorities recommend 1 pediatric neurosurgeon per 3 millions inhabitants. In Paris, 6 full-time neurosurgeons, 5 residents, 1 part-time cranio-facial surgeon, 1 neurologist and 3 psychologists manage the department. Each senior, although qualified for any type of neurosurgery, has his own domain of interest and a cranio-facial unit is individualized. The department has the monopoly of the emergency cases from Paris and its region. This means a daily average of 10 phone calls for advice, 4 consultations, 3 hospitalizations, 1 emergency surgery, 1.5 delayed surgeries. One third of these patients are below 1 year, 1/3 between 1 and 10 yrs and the last 1/3 over 10. Hydrocephalus and tumors account for respectively 21% and 20% of these emergency cases. This activity is under the responsibility of a senior and of a resident. After midnight, the senior remains on call, but can stay out of the hospital, due to the strikingly decreasing activity passed this time.

UNESCO recommendations for in hospitalized children

The respect of the UNESCO chart for in hospitalized children is an obligation. This chart gives rights to the parents to stay day and night besides their child without financial consequences. It also makes obligatory the prevention and treatment of pain, the regrouping of children by age bracket, and the existence of specific spaces for ludic activities and education. The NEM department of neurosurgery reserves a special space for teaching and games. In the future building, this space will be shared with the other units of the building.

Recommendations for Pediatric Neurosurgery training

European and French recommendations imply a 5 year residency, with a minimum of 3 years in general neurosurgery, 6 months in general surgery, 6 months minimum in a reference center of pediatric neurosurgery, the rest in neurology, neuroradiology or neuropathology.

To be qualified as pediatric neurosurgeon one must have spent one year minimum as senior resident in a reference center of pediatric neurosurgery in France or abroad and have followed the complete cycle of the European course for pediatric neurosurgery.

Prospective

In a next future, the nature of the pathologies referred to neurosurgeons as well as the modalities of their treatment will change, probably leading to reconsider the architecture and the functioning of a structure of pediatric neurosurgery. Shortening of hospitalizations will result from ambulatory surgery, minimally invasive surgery, neuroendoscopy, robotic, new oncologic treatments but might well be counterbalanced by the need for more and more functional surgery requiring long stays in hospitals. The need for super specialized pediatric departments or units could well be a trend. This is already the case in Paris where the quasi totality of the cranio-facial and tumor surgeries are made in NEM while the majority of the epilepsy surgery is referred to a private hospital. Education and formation of pediatric neurosurgeons will follow the same slope. The need for super specialized neurosurgeons will probably become necessary. In France, the major actual problem is related to a decreasing medical demography. While the ratio of neurosurgeons is 1/81000 in the US, 1/67000 in Germany, 1/105000 in average in Europe, it is only 1/170000 in France. Their number and among them the number of pediatric neurosurgeons is hardly sufficient to take in charge the 6000 children requiring each year a neurosurgical treatment. The advantage of such a low number of surgeons is to guarantee a rapid and large experience, but the task may rapidly become beyond our means, especially knowing the high number of neurosurgeons on the way to retire. In our country, recruitment of young neurosurgeons and, among them, of pediatric neurosurgeons is the actual priority.

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