South African Journal of Surgery - latest Issue
Volume 54, Issue 4, 2016
Author Ravi OoditSource: South African Journal of Surgery 54, pp 1 –32 (2016)More Less
Ventral hernia repair is one of the most common general surgical procedures. The best opportunity for a successful outcome is the first repair. The last two decades has seen significant advances in surgical technique, types of mesh, fixation devices imaging techniques and the understanding of abdominal wall biomechanics. In addition, there has been a shift to a patient centered, evidenced based care and the importance of measuring outcomes increasingly recognized.
This has resulted in a significant shift in approach to hernia care worldwide. Despite these advances internationally, change has been slow in South Africa. It is clear that teaching, training and management in herniology need to be prioritized in South Africa. Care pathways need to shift to a tailored, patient-centered, evidence and consensus based paradigm and patient outcomes need to be measured.
The Hernia Interest Group of South Africa (HIG) established these guidelines with a view to creating a platform for change. These are the first national and international guidelines addressing both open and laparoscopic ventral hernia care. The HIG has presented objective, locally relevant guidelines that we believe will be useful to all surgeons, referring doctors, the health care industry and funders. The establishment of guidelines is a dynamic process and the intention is to update the guidelines every three years.
Author D.M. DentSource: South African Journal of Surgery 54, pp 2 –2 (2016)More Less
When should surgeons retire? Do they have a defined shelf life and a sell-by date? At what point should they chuck in the scalpel and hang up their gloves? The answer to these questions for young and old surgeons is found by them merely looking around themselves: the young to make continuous mental notes about what to do (and not to do) when they get older; older surgeons to do so as a reality or insight check. The first gaze is at the theory and understanding that underpins surgery – academic surgery if you will – and the second gaze is at the craft of cutting, for surgeons are really just journeymen-craftsmen, the better ones with well-developed cognitive and manipulative skills.
Author I BuccimazzaSource: South African Journal of Surgery 54, pp 3 –4 (2016)More Less
Everyone ages, and so do surgeons. No one seemed to mind that Professor Michael DeBakey was 88 years old and still performing open heart surgery when he operated on the Russian President Boris Yeltsin. But is there a point beyond which the surgeon’s age becomes a risk factor?
Author D.A. ThomsonSource: South African Journal of Surgery 54, pp 5 –6 (2016)More Less
In state service in South Africa, retirement is mandatory for doctors at 65 years while in private practice retirement age is not regulated. Is surgical retirement age an issue? Professor Michael DeBakey famously continued to operate until he was 90. Surely a lifetime of experience offsets the inevitable decline in motor and cognitive function that comes with age? There is however a growing body of evidence that physician experience and age is linked to worse patient outcomes. In one meta-analysis, 74% of studies showed a negative association between physician age and recognized standards of therapeutic care.
Enhanced recovery after surgery (ERAS) in penetrating abdominal trauma : a prospective single-center pilot studySource: South African Journal of Surgery 54, pp 7 –10 (2016)More Less
Background: Enhanced recovery after surgery (ERAS) programmes employed in elective surgery have provided strong evidence for decreased lengths of hospital stay without increase in postoperative complications. The aim of this study was to explore the role and benefits of ERAS implemented in patients undergoing emergency laparotomy for penetrating abdominal trauma.
Methods: Institutional University of Cape Town Human Research Ethics Committee (UCT-HREC) approved study. A prospective cohort of 38 consecutive patients with isolated penetrating abdominal trauma undergoing emergency laparotomy were included in the study. The enhanced recovery protocols (ERPs) included: early urinary catheter removal, early nasogastric tube (NGT) removal, early feeding, early mobilisation/physiotherapy, early intravenous line removal and early optimal oral analgesia. This group was compared to a historical control group of 40 consecutive patients undergoing emergency laparotomy for penetrating abdominal trauma, prior to the introduction of the ERP. Demographics, mechanism of injury, injury severity scores (ISS) and penetrating abdominal trauma index (PATI) were determined for both groups. The primary end-points were length of hospital stay (LOS) and incidence of postoperative complications (Clavien-Dindo classification) in the 2 groups. The difference in means was tested using the t-test assuming unequal variances. Statistical significance was defined as p-value less than 0.05 (p < 0.05).
Results: The two groups were comparable with regards to age, gender, mechanism of injury, ISS and PATI scores. The mean time to solid diet, urinary catheter and nasogastric tube (NGT) removal was 3.6 (non-ERAS) and 2.8 (ERAS) days [p < 0.035], 3.3 (non-ERAS) and 1.9 (ERAS) days [p < 0.00003], 2.1 (non-ERAS) and 1.2 (ERAS) days [p < 0.0042], respectively. There was no difference in time from admission to time of laparotomy 313 (non-ERAS) vs 358 (ERAS) minutes [p < 0.07]. There were 11 and 12 complications in the non-ERAS and ERAS groups, respectively. When graded as per the Clavien-Dindo classification, there was no significant difference in the 2 groups (p < 0.59). Hospital stay was significantly shorter in the ERAS group: 5.5 (SD 1.8) days vs. 8.4 (SD 4.2) days [p < 0.00021].
Conclusion: This pilot study shows that ERPs can be successfully implemented with significant shorter hospital stays without any increase in postoperative complications in trauma patients undergoing emergency laparotomy for penetrating abdominal trauma.
Source: South African Journal of Surgery 54, pp 11 –16 (2016)More Less
Introduction: The aim of this study was to audit the use of Computerised Tomographic Angiography (CTA) in assessing extremity vascular injuries at our institution and to compare it to international standards. The primary aim was to assess the number of CTAs performed and the indications for doing them. The secondary aim was to look at CTA results and clinical findings and to correlate the two.
Methods: This is a retrospective review of all patients aged 13 years and older who had CTA performed for suspected extremity vascular injuries due to blunt trauma or gunshot injuries, who presented from January 2012 to December 2012.
Results: Two hundred and eighty five (285) CTAs were performed in 2012 and 137 met our inclusion criteria. Eleven cases were excluded due to insufficient data, leaving a total of 126 cases suitable for analysis. Eighty three patients (66%) had a normal CTA. The indications for CTA were as follows: decreased pulse in 46 patients (42%), absent pulse in 19 patients (17%), presumed knee dislocation in 18 patients (16%), injuries in the proximity of large vessels in 12 patients (11%), haematoma in 8 patients (7%), bleeding in 5 patients (4%) and an abnormal Doppler in 2 patients (2%). When comparing pulse examination to CTA results, the clinical assessment of pulses had a sensitivity of 74.4%, specificity of 53.7%, positive predictive value (PPV) of 45.7% and a negative predictive value (NPV) of 80%.
Conclusion: Incorrect indications are being used when ordering a CTA in extremity vascular trauma. Clinical examination is suboptimal and not a reliable indicator of vascular injury in our setting, leading to a lower threshold for ordering a CTA.
The effect of emergency medical services response on outcome of trauma laparotomy at a Level 1 Trauma Centre in South AfricaSource: South African Journal of Surgery 54, pp 17 –21 (2016)More Less
Background: Due to resource constrained pre-hospital emergency medical services (EMSs) there is a significant delay in injured patients arriving at Groote Schuur Hospital Trauma Centre (GSHTC). The aim of the study was to examine the effectiveness of EMSs in transferring trauma patients to GSHTC. The effect of any delay to laparotomy from injury was noted.
Methods: A prospective audit of patients presented directly from the scene to GSHTC following abdominal trauma over a four-month period was performed. Time from contact to the arrival of EMS at scene – the response time (RT) – was used as an indicator of EMS performance. Postoperative complications were graded according to Clavien-Dindo classification of surgical complications.
Results: A total of 118 patients were admitted to the trauma surgery ward following abdominal trauma. The mechanism was penetrating 101 (85.6%) [stab wounds in 67 (56.8%) and gunshot in 34 (28.8%)], and 17 (14.4%) with blunt injuries. EMSs transported 110 (93.2%) patients. A total of 48 index laparotomies were done during this period, of which 13 patients developed postoperative complications. The median RT of the EMS after contact was 53 min for patients who developed complications. It was significantly longer than for those without complications, 21 min (p < 0.01). The median delay to laparotomies from injury for patients with postoperative complications was 10.3 hours and for those without complications was 7.5 hours. The delay from injury to the theatre was also a significant factor in the development of complications (p = 0.02).
Conclusion: The response delay by EMS and delay from injury to the theatre increased complications. Therefore, rapid response by EMS in transferring trauma patients needs to be strengthened.
Trauma unit attendance : is there a relationship with weather, sporting events and week/month-end times? An audit at an urban tertiary trauma unit in Cape TownSource: South African Journal of Surgery 54, pp 22 –27 (2016)More Less
Background: The Groote Schuur Hospital Trauma Unit is a high-volume referral center where patient volumes may be related to temporal and environmental factors.
Objective: This audit aimed to determine if numbers of patients presenting after motor vehicle collisions (MVCs) and interpersonal violence (IPV) were related to temporal factors, weather variables and important soccer matches.
Method: Numbers of patients presenting to the unit per shift over 17 months were obtained from unit logs. Weather data, local soccer match locations and results, and information regarding public holidays and long weekends were obtained for the relevant shifts. Average daily attendances for IPV-related injuries and MVCs were compared across the various external factors described. Poisson regression models were fitted and used to express the relative incidence of attendances. These results are expressed using incidence rate ratios (IRRs).
Results: For the study period, 7 350 attendances due to IPV-related injuries, and 3 188 injuries due to MVCs were recorded. Weekdays, long-weekend nights and month-end weekends had increased MVC-related attendance. Precipitation also increased attendances related to MVCs. Public holidays had less MVC-related attendance. IPV-related attendances were increased at night, on long weekends, and on month-end weekends. Weekend shifts were busier than weekday shifts, particularly at month-end. Long weekends showed similar trends to ordinary weekends, and public holidays showed similar trends to ordinary weekdays. Increasing temperatures are associated with increased attendances. Soccer matches and their outcomes have no significant effect on IPV-related attendances.
Conclusion: Temporal and weather factors can help predict which trauma unit shifts will be busiest.
Source: South African Journal of Surgery 54, pp 28 –33 (2016)More Less
Background: Acute extradural haematomas (AEDHs) occur infrequently in children. This study was undertaken to review our experience with management and outcomes of this condition in children treated in the Neurosurgery Unit at Inkosi Albert Luthuli Central Hospital.
Methods: A retrospective review of medical records of all children (age less than or equal to (≤) 12 years) with a diagnosis of AEDH admitted from January 2003 to December 2014 was performed. Records were analyzed for demographics, mechanisms of injury, clinical presentation, neuroradiology findings, management and outcomes at discharge.
Results: A total of 150 children with AEDHs were admitted during this period. The mean age was 6.6 ± 3.8 years with a peak incidence in the 7-9 year age group. There were 84 (56%) males, (M: F= 1.3:1). Sixty AEDHs resulted from road traffic crashes (40%). On admission 104 (69.3%) children were Glasgow coma scale (GCS) 13-15, 26 (17.3%) GCS 9-12 and 20 (13.4%) GCS 3-8. Haemoglobin was less than (<) 8 g/dl in 56% of infants (p < 0.001). Skull fractures were identified in 78% of cases. Surgical management was undertaken in 83% of children and the mean hospital stay was 6.9 ± 6.1 days. Four children (2.7%) died during in-hospital stay period. One hundred and forty one (94%) children had a favourable Glasgow outcome scale (GOS) at discharge.
Conclusion: AEDHs in children carry a good prognosis, but can be potentially fatal. A vigilant approach is required when assessing these children, as early diagnosis and treatment yields gratifying results.
Comparative study of extralevator vs. conventional abdominoperineal excision in a single centre in the developing worldSource: South African Journal of Surgery 54, pp 34 –39 (2016)More Less
Abstract: Abdominoperineal excision (APE) is used to resect cancers in the distal rectum and anus where sphincterpreserving surgery is not possible. It is associated with increased local recurrence rates compared to anterior resection. The extralevator abdominoperineal excision (ELAPE) was developed to reduce local recurrence and was widely adopted without sound evidence.
Aim: To compare the short-term (2 years) outcomes of patients managed with ELAPE to those with conventional APE in a single institution in a developing country.
Methods: A prospective database on all patients treated with prone ELAPE from 2010 to 2014 was compared to patients treated with conventional APE. Patient demographics, tumour characteristics, intra-operative tumour perforation, involvement of the circumferential resection margin (CRM), surgical complications and mortality are reported.
Results: Fifty-six patients were treated with APE of which 29 were male. Median age was 56. Thirty underwent conventional APE (16 male; 14 female) and 26 underwent ELAPE (15 male; 11 female). The groups were similar in age, tumour histology, height above anal verge clinical staging and response to neoadjuvant treatment. Perineal closure techniques in both cohorts were similar. There was no difference in intra-operative tumour perforation, involvement of the CRM, perineal wound complications or 30-day mortality in the 2 groups.
Conclusion: There is no difference in the important short-term outcomes of conventional APE when compared to ELAPE.
A fifteen year experience of total thyroidectomy for the management of simple multinodular goitres in a low medium income countrySource: South African Journal of Surgery 54, pp 40 –45 (2016)More Less
Introduction: Total thyroidectomy as a treatment for simple multinodular goitre is not well recognised in most centres in low middle income countries.
Methods: This paper is a retrospective review of outcomes of total thyroidectomy for simple multinodular goitres in the last fifteen years in a tertiary hospital in Nigeria.
Results: A total of 652 thyroidectomies were done from January 2001 to December 2015. Simple multinodular goitres were indication for a total thyroidectomy in 447 patients (68.6%) with a male to female ratio of 1:6. Postoperative complications were hypocalcaemia in 22 (4.9%), unilateral recurrent laryngeal nerve palsy in 13 (2.8%) and haemorrhage in 2 patients. Others were seroma and cellulitis. Tracheostomy was required in 35 (5.8%) patients but none was permanent.
Conclusion: Total thyroidectomy is a relatively safe treatment option for patients who have simple multinodular goitre. It provides a permanent cure with a low postoperative morbidity risk. The burden of replacement l-thyroxine needs to be discussed with the patients.
Macromastia and gigantomastia : efficacy of the superomedial pedicle pattern for breast reduction surgerySource: South African Journal of Surgery 54, pp 46 –50 (2016)More Less
Background: Reduction mammoplasty procedures in patients with macromastia and gigantomastia can prove a major challenge to the plastic surgeon. Although several techniques have been described to reduce very large breasts, they can often result in vascular compromise to the nipple-areola complex (NAC) and skin flaps, decrease in NAC sensation and inability to breast-feed. The superomedial pedicle (SMP) procedure is often used in patients with moderate to large breast reductions. For extremely large breast reductions, macromastia and gigantomastia breast amputation with a free nipple graft is often recommended. For large resections and long suprasternal notch-nipple (N-N) distances there is no consensus in terms of approach.
Objective: To evaluate the efficacy and complication rate of the SMP reduction mammoplasty technique for extremely large, macromastia and gigantomastic breasts at two institutions in Johannesburg.
Methods: Retrospective review of patient records with macromastia and gigantomastia who had undergone the SMP technique reduction mammoplasty between 2008 and 2012. Complications were assessed at 1 week, 3 weeks, 6 months and a mean of one year postoperatively.
Results: There was a total of 31 patients, 62 breasts, with macromastia and gigantomastia who had an SMP pattern of reduction. The mean age was 30.1 years, mean BMI was 28.1 and average resection weight from each breast was 1835 g. The mean N-N was 44.13 cm. The majority, 90% of patients had a good aesthetic outcome with less than 20% having any long-term complications, which were all relatively minor.
Conclusion: The SMP reduction mammoplasty efficiently reduces extremely large breasts while preserving the vascular integrity and sensation of the NAC, while simultaneously providing a well-shaped, projecting breast in macromastia and gigantomastia patients.
Source: South African Journal of Surgery 54, pp 52 –57 (2016)More Less
Background: Acute complex traumatic wounds of the lower limbs are usually managed by a combination of multiple debridements, dressing changes, and specialized surgical procedures which may include tissue transfers for the reconstruction of the soft tissue injury. The recovery is lengthy, and the outcome dependent on the initial injury, the surgical procedures undertaken and rehabilitation programs with a multidisciplinary team.
Methods: A nine-year-old male patient presented to Kimberly Hospital with an extensive soft tissue injury of the leg associated with a tibia fracture caused by a high velocity pedestrian vehicle accident.
Results: A combination of proper wound care, “homemade” negative pressure wound therapy dressings, reduction of fracture and use of a dermal regeneration template over the fracture site, followed by skin grafting was used to manage the wound.
Conclusion: The final functional and cosmetic results obtained with the case suggest that the dermal regeneration template may provide a potential alternative for coverage of complex wounds, which might include an open fracture, without the need for complex tissue transfer interventions.
Source: South African Journal of Surgery 54, pp 58 –64 (2016)More Less
Covering tibial bone exposure from third degree burns to the lower limbs is a challenging task for the plastic surgeon. We present our experience of covering tibial exposure from burns in three different patients, where four limbs were involved and three muscular flaps were used in conjunction with one another; i.e. the tibialis anterior flap, the medial gastrocnemius flap and the hemisoleus flap. Through the use of this technique, tibial bone exposure, ranging from 15–30 cm, was successfully covered. This technique constitutes a good solution for surgically challenging wounds.