age) are far lower than the recommended workforce size. Complex conditions require a significant increase in the number of paediatric surgeons. In contrast, children with minor diseases, living in rural areas, could be managed even at the district level by trained general surgeons.Aim: The aim of this study was to develop capacity for general paediatric surgical services in a district hospital by outreach with a focus on mentorship.Methods: Capacity building priorities for non-specialist paediatric surgery were identified and addressed using evidence-based guidelines. Local general surgeons were involved in supervised clinical decision-making and in all surgical procedures. The visiting team provided daily meetings, weekly lectures, and on-job training. Electronic copies of recent surgical textbooks were provided together with video-conferencing distant specialist consultations.Results: A total of 715 children were handled by the visiting team during the 27-week period. Four hundred and fifty diseases were diagnosed amongst 406 children. Awareness of paediatric surgical needs, improved management of most common conditions like congenital hernias, undescended testis, hypospadias and anorectal malformations needing temporary colostomy occurred. Local general surgeons were assisted in treating 358 cases of general paediatric surgical conditions. Updated early management protocols were introduced for more complex diseases needing referral to specialist centres like solid tumours and neonatal abnormalities. The visiting team operated major paediatric surgical cases at the Consolata Hospital Ikonda.Lessons learnt: Surgical outreach and capacity building at the district hospital level could be a possible answer to the unmet paediatric surgical needs of children living in rural areas. Apprenticeship training for general surgeons may help to fill the gap provided that they are strongly motivated and supported on acquiring and implementing their paediatric surgical skills.

Background: One-step pull-through for Hirschsprung’s disease (HSCR) is already standard in many tertiary African paediatric surgical centres where radiology and frozen sections are available. However, limited resources in many peripheral areas associated with advanced age at referral or complicated presentation make recourse to colostomy often unavoidable with a consequent three-step surgery. To simplify these children’s clinical course and spare the burden of a third procedure for colostomy reverse, a direct pull-through of the proximal ganglionic stoma is proposed. Materials and Methods: Twenty children (male/female ratio 19/1) between 3 months and 13 years with a colostomy for a suspected HSCR were selected for stoma pull-through among patients admitted to a regional Tanzanian hospital between 2016 and 2022. Histological diagnosis was always confirmed by rectal biopsies and, in some cases, colonic specimens taken during the stoma confection or revision. A ganglionic stoma was always ascertained before the pull-through procedure (11 Transanal Endorectal, 4 Soave and 5 Duhamel). Results: One death was registered in a child with Down syndrome, unrelated to surgery, and another due to HSCR acute associated enterocolitis. One stenosis required stricturoplasty, and one anastomotic leakage needed temporary ileostomy. No relationship was found between complications and the procedure of choice. Passage of stools started on the 2nd day and became regular and without soiling in a week. Conclusions: Straightforward pull-through of the ganglionic stoma may be a feasible solution for patients with HSCR and a diverting colostomy to avoid a three-step procedure. The correct position of the stoma at the transition zone must be ascertained to avoid the risk of including in the resection segment of the ganglionic bowel.

Introduction: In sub-Saharan Africa, Anorectal malformations (ARM) are the most frequent cause of neonatal obstruc- tion. Referral to a Pediatric Surgeon is frequently delayed. The first treatment is often delivered at not specialist level and mismanagement may result. Aim: To study ARM patients referred beyond neonatal period and managed at a non-specialist level. Materials and Methods: One hundred and thirty patients were included (M/F ratio 63/67) among 144 admitted to three Eastern African Hospitals with Pediatric Surgical facilities. Demographics, type of anomaly, delay on referral, previous man- agement, most commonly observed errors are reported. Results: The Mean age at referral was 23 months (range five weeks – 23 years). Colostomy was the most frequent surgery (92 cases). Stomas often did not follow the recommended criteria. Ten per cent were not on the sigmoid, and 35% were not divided. "Loop" or "double-barrel" colostomies did not exclude the distal loop. Inverted (10,5%), prolapsed stomas (7,5%), short distal loop (16%) were observed. Twenty-four cases (26%) needed redo. Primary perineal exploration in eight patients resulted in incontinence. Conclusions: Investments on training practitioners, acting at District/Rural level, and closer links with tertiary centres are recommended to avoid ARM mismanagement and delayed referral to a Specialist. Keywords: Ano rectal malformations; neonate; low resources context.